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THE  UNSOUND  MIND  AND  THE  LAW 

A  PRESENTATION  OF  FORENSIC 
PSYCHIATRY 


BY  THE  SAME  A UTHOR 

Child  Training 

As  An  Kxact  Science 


A  Treatise  Based  Upon  the  Principles  of 
Modern  Psychology,  Normal  and  Abnormal 
WITH  IS  FULL-PAGE   ILLUSTRATIONS 

This  profoundly  interesting  volume  grew  out  of 
Dr.  Jacoby's  long  years  of  exceptional  study  and 
practise  as  a  neurologist.  It  covers  a  practically  new 
field  on  the  subject  of  child-training  in  its  mental, 
moral  and  physical  aspects. 

What  Experts  Have  to  Say  of  It 

"A  distinct  contribution  to  the  child  welfare  movement .... 
The  mentally  defective  child  is  one  of  the  most  important  prob- 
lems of  our  time.  Dr.  Jacoby's  book  will  help  us  to  solve  this 
problem."  —  S.  Josephine  Baker,  M .  D.,  Director,  Bureau  of 
Child  Hygiene,  Department  of  Health,  New  York  City. 

"  This  book  appeals  to  the  physician,  teacher,  and  parent,  as 
it  shows  how  the  active  cooperation  of  the  three  can  be  used  to 
the  advantage  of  the  child.  From  the  standpoint  of  each  the 
volume  appeals  with  telling  force." 

—  Medical  Times,  New  York,  N.  Y. 

''Without  doubt  one  of  the  most  suggestive  and  helpful  pres- 
entations of  this  subject  yet  written  for  the  teacher  and  parent." 
— Social  Hygiene,  Baltimore,  Md. 

"A  volume  that  can  not  fail  to  be  both  interesting  and  valu- 
able to  the  general  reader  as  well  as  to  the  physician  and 
educator." — Medical  Record,  New  York,  N.  Y. 

12mo,   Cloth.  $1.50,   Net. 


FUNK   &  WAGNALLS   COMPANY,  Publishers 
NEW  YORK  and   LONDON 


THE  UNSOUND  MIND 
AND  THE  LAW 

A  PRESENTATION  OF 
FORENSIC  PSYCHIATRY 


BY 

GEORGE  W.  JACOBY,  M.D. 

AUTHOR  OF  "CHILD  TRAINING  AS  AN  EXACT  SCIENCE" 
Fellow  of  the  New  York  Academy  of  Medicine,  Member  of  the  American 
Medical  Association,  American  Neurological  Association,  and  New 
York  Neurological  Society,  Consulting  Neurologist  to  the 
Hospital  for  Nervous  Diseases,  The  German  Hos- 
pital, The  Beth  Israel  Hospital,  The  Bed 
Cross  Hospital,  and  the  Infirmary 
for  Women  and  Children 
in  the  City  of 
New  York, 
etc. 


FUNK  &  WAGNALLS  COMPANY 

NEW  YORK  AND  LONDON 
1918 


Copyright,  1918,  by 

FUNK  &  WAGNALLS  COMPANY 

Copyright  under  the  Articles  of  the  Copyright  Convention  of  the 

Pan-American  Republics  and  the  United  States,  August  11,  1910 

(PBINTED  IN  THE  UNITED  STATES  OF  AMERICA) 

Published  November,  1918 


PREFACE 

Most  English  or  American  books  on  forensic  psychiatry  have 
a  distinct  tendency  to  subordinate  the  medical  viewpoints  to 
the  juristic  ones  as  the  latter  find  their  expression  in  our  pre- 
vailing laws  and  judicial  decisions.  The  extent  to  which  the 
subject-matter  must  consequently  suffer  becomes  particularly 
manifest  when  the  more  recent  advances  in  psychiatric  medicine 
are  contrasted  with  the  conservatism,  or  let  us  rather  say  stag- 
nation, that  exists  in  English  and  American  laws  in  the  same 
field. 

Wherever  the  existing  law  and  modern  medicine  disagree, 
there  is  a  tendency  to  give  the  former  a  more  plausible  recog- 
nition than  it  actually  deserves,  or  to  assume  that  the  latter, 
notwithstanding  its  scientific  basis,  is  at  least  problematic,  and 
therefore  to  attempt  to  fashion  it  to  accord  with  the  juristic 
mold. 

The  lack  of  courage  to  admit  frankly  the  inadequacies  or 
inequities  of  the  partly  antiquated  law  is  defended  by  the 
specious  plea  of  "practical  social  needs."  In  the  borderland 
cases  where  doubt  exists  as  to  whether  a  legal  or  a  medical 
remedy  should  be  applied,  the  criminal  law  supposedly  meets 
these  "needs"  best  by  committing  the  anti-social — that  is,  the 
insane — elements  of  the  community  to  prison  instead  of  to  a 
hospital.  We  will  admit  without  reserve  that  even  the  most 
ideal  law  cannot  fully  accord  with  all  the  requirements  of 
medical  science,  for  social  order  demands  a  more  or  less  cate- 
gorically incisive  legal  treatment,  which  in  the  individual  case 
may  act  as  a  hardship,  occasionally  even  as  an  injustice.  But 
it  is  certainly  the  duty  of  our  lawmakers  to  prevent  such  hard- 
ship or  injustice  as  far  as  lies  within  human  power. 

The  science  of  medicine  must  constitute  the  logical  basis  for 
every  treatise  on  juristic  psychiatry,  for  the  medical  facts  alone 
are  stable,  even  if  their  scientific  recognition  may  be  uncertain 
and  may  vary  with  the  lapse  of  time.  Legislation,  however,  is 
always  subject,  and  necessarily  so,  to  relatively  arbitrary  and 


vi  PREFACE 

often  illogical  changes.  In  the  nature  of  things,  it  should  adapt 
itself  to  the  science  of  medicine;  the  contrary  procedure  is 
entirely  out  of  the  question. 

That  psychoses  do  not  differ  from  other  diseases,  that  they  are 
usually  conjoined  with  states  of  bodily  disorder,  and,  conse- 
quently, that  insane  asylums  are  nothing  other  than  hospitals 
adapted  to  the  special  requirements  of  patients  suffering  from 
diseases  of  the  brain  and  nervous  system,  constitute  funda- 
mental truths  which  must  become  part  of  every  person's  knowl- 
edge. Not  until  these  truths  are  generally  recognized  will  the 
final  prejudice  disappear  against  those  who  are  mentally  dis- 
turbed and  against  the  asylums  for  the  insane;  and  only  then 
will  the  relationship  between  jurisprudence  and  psychiatry  be 
of  a  more  intimate  and  harmonious  nature.  Meanwhile,  it 
becomes  the  duty  of  every  neurologist  and  psychiatrist  to  con- 
tribute his  share  to  the  practical  extermination  of  the  extraor- 
dinary conceptions  of  mental  disorder  that  conflict  so  sharply 
with  our  present-day  knowledge  and  not  infrequently  place 
insuperable  obstacles  in  the  way  of  correct  juristic  estimation 
of  medico-legal  problems  affecting  the  insane.  It  is  this  thought 
that  has  been  my  chief  incentive  in  writing  the  present  treatise. 

In  the  first  main  division  of  the  book  I  purpose  treating  of 
the  general  relation  that  jurisprudence  bears  to  psychiatry  and 
more  especially  to  consider,  in  addition  to  simulation  and  dis- 
simulation and  the  self-accusations  of  the  insane,  the  various 
degrees  of  responsibility  and  the  significance  they  bear  to  our 
civil  and  criminal  procedures. 

The  second  main  division  will  be  devoted  to  psychiatric 
expertism  and  will  describe  the  manifestations  by  means  of 
which  the  most  important  psychoses  and  neuro-psychoses  may 
be  recognized.  The  third  part  is  devoted  to  a  consideration  of 
hypnosis  and  anomalies  of  sexual  sense,  and  the  fourth  and  last 
part  will  indicate  the  manner  in  which  written  or  verbal  expert 
opinions  are  to  be  formed  and  rendered. 

In  this  work  I  hope  to  be  able  to  do  justice  to  the  require- 
ments of  the  physician  as  well  as  to  those  of  the  jurist.  It  has, 
however,  been  far  from  my  purpose  to  write  a  book  on  forensic 
psychiatry  in  general,  for  which  reason  I  have  endeavored  to 
limit  myself  to  those  questions  of  juristic  psychiatry  that  may 
be  designated  as  "borderline." 


CONTENTS 

PAGE 

Introduction 3 

The  physician's  need  for  juristic  knowledge;  the  jurist's  need 
for  medical  knowledge;  the  contradictions  that  exist  between 
legal  enactments  and  modern  psychiatry;  the  physician's  testi- 
mony in  doubtful  states  of  mental  disease — Simulation  and  dis- 
simulation; the  judge's  dilemma  in  borderline  cases;  necessity 
for  expert  advice;  the  psychiatrist's  expert  opinion — The  insane 
as  persons  who  are  physically  sick — No  mental  activity  indepen- 
dent of  the  brain — Questionable  states  of  mental  disorder;  the 
difficulties  that  surround  their  legal  appreciation — Eecognition  of 
right  and  wrong  not  a  test  for  free  determination — Physicians' 
and  jurists'  view  of  responsibility — Delusions  as  a  test  for  men- 
tal disorder — The  complexity  of  notions  of  responsibility  and 
irresponsibility — Morbid  impulses — The  considerations  that  are 
vital  in  a  forensic  estimation  of  doubtful  cases  of  mental  dis- 
order. 

Part  First  :    The  General  Relations  of  Jurisprudence 
and  Psychiatry. 

I.     historical  retrospect 19 

No  knowledge  comes  as  a  revelation,  as  a  gift;  recognition  differ- 
ent from  mere  knowledge — The  historical  development  of  the 
teachings  of  mental  disorder  in  ancient  times — The  teachings 
of  Hippocrates — Psychiatry  among  the  Romans — Psychiatry  as 
an  accredited  science — Influence  of  the  Greeks — Celsus  and  Galen 
— Galenic  medicine  in  general  and  Galenic  psychiatry  in  par- 
ticular— Guardianship  proceedings — The  teachings  of  mental  dis- 
order in  the  middle  ages — Scholastic  domination — Philosophy 
and  scholasticism — The  decline  of  medieval  psychiatry  as  a 
result  of  prejudice  and  superstition — Psychiatry  in  modern  times 
— The  influence  of  new  inventions  and  discoveries — Advantages 
derived  from  the  studies  of  the  Humanists — Paracelsus — The 
eradication  of  the  belief  in  astrology,  alchemy  and  witchcraft — 
Eeform  in  the  study  of  anatomy — Vesalius — Inductive  investi- 
gation— Francis  Bacon — Reil  the  founder  of  the  modern  science 
of  anatomy  and  physiology  of  the  central  nervous  system — Medi- 
cal expertism  among  the  Greeks  and  Romans — Galen's  recog- 
nition of  simulation  and  that  of  Zachias — The  treatment  of  sim- 
ulation in  the  17th  and  18th  centuries — Vitalism — The  moderate 
vitalists — Hahnemann's  views — England  as  pioneer  in  the  hu- 
mane care  of  the  insane — The  same  movement  in  France — The 
investigation  of  pathological  anatomy  as  a  cause  of  growth  of 
the  French  school — Bichat  in  France,  Reil  in  Germany,  Bell  in 
England — The  conclusions  of  Spurzheim  and  Gall — Progress  in 
Holland  and  Germany — Advances  in  knowledge  due  to  modern 
studies  and  investigations — The  systematic  classification  of  psy- 
choses and  neuropsychoses — The  recognition  of  diminished  re- 

vii 


viii  CONTENTS 

PAGE 

sponsibility  or  restricted  freedom  of  the  will — Self-accusations 
of  the  insane — Moral  depravity  or  disease — Sero-diagnosis  in 
psychiatry. 

n.  THE  NOTIONS  OF  MENTAL  DISORDER  ....  53 
No  sharp  dividing  line  between  health  and  disease — The  "nor- 
mal type"  a  fiction — "Borderline  states"  not  to  be  judged  by 
individual  symptoms — Nature  distinguishes  no  classes  but  only 
individuals — The  difficulty  of  classifying  mental  disease — All 
functional  disorder  based  upon  organic  change — Every  symp- 
tom must  have  a  material  basis — Psychoses  must  have  a  material 
basis — ' '  Degenerative  signs ' '  in  forensic  psychiatry — Unrelia- 
bility of  such  signs — When  do  emotions  cease  to  be  normal? 
Pedagogy  and  individuality — Misdirected  education  as  a  cause 
of  conflict  with  the  law — Transitional  mental  states  should  re- 
ceive proper  recognition. 

m.      PSYCHOPATHIC    DISPOSITION 64 

General  capability  as  a  gauge  of  health  or  sickness — Disturb- 
ances of  efficiency  and  disordered  function — The  essential  fac- 
tors in  the  causation  of  disease — Predisposition,  power  of  adapt- 
ability, diminished  resistibility — No  sharp  boundary  line  be- 
tween predisposition  and  disease — The  determination  of  in- 
herited disposition — The  hereditary  transmission  of  pathological 
qualities — Johann  Gregor  Mendel — The  application  of  the  Men- 
delian  law  to  human  heredity  and  development  of  physical  traits 
— The  hereditary  transmission  of  an  acquired  disposition  to 
disease — The  effects  of  alcohol  upon  heredity. 

rV.  EXOGENOUS  CAUSES  OF  MENTAL  DISEASE  ...  73 
Psychic  shock  or  bodily  disorder  of  itself  not  a  cause  of  insanity 
— No  absolute  immunity  to  mental  disease — Racial  immunity  or 
other  congenital  insusceptibility  does  not  exist — A  comparison 
of  country  life  and  city  life  as  factors  in  the  causation  of  in- 
sanity— Environment  and  pursuit  as  important  productive  causes 
— Favorable  and  unfavorable  conditions  of  life — Over-exertion, 
Dissipation — Cooperation  of  psychopathic  taint  and  extrinsic 
causes — Gradual  development  of  all  psychoses — Anatomical 
changes  but  rarely  to  be  considered  as  the  cause  of  an  insanity. 

V.      MENTAL  DISORDER  AND  RESPONSIBILITY 

A.  The  Physiologic-Psychologic  Basis  of  Responsi- 

bility         80 

The  concept  of  responsibility — Responsibility  and  irresponsibil- 
ity— Borderline  states  and  restricted  responsibility — Freedom  of 
the  will  and  determination — The  classification  of  the  individual 
forms  of  mental  disorder — The  earliest  manifestations  of  in- 
sanity, their  recognition  more  important  and  more  difficult  than 
that  of  bodily  disease. 

B.  Mental  Disorder  as  a  Physical  Disease  .  .  88 
Mental  disorders  as  disorders  of  bodily  activity — The  Abderhal- 
den  method  as  a  means  of  early  recognition  of  mental  disease — 
Defensive   ferments — Toxamiia  and  endogenetic  poisoning — The 


CONTENTS  ix 

PAGE 

ductless  glands — Mutational  relations  of  the  organs  of  internal 
secretions — The  diagnostic  value  of  the  defensive  ferments — As 
many  kind  of  defensive  ferments  as  there  are  pathological  proc- 
esses— The  serum  test  in  the  recognition  of  psychoses — Status 
somaticus  and  status  psychicus — Psycho-physical  parallelism. 

VI.  THE  EXAMINATION  OP  THE  INSANE  ....  98 
No  experimental  study  admissible  in  a  forensic  psychiatric  ex- 
amination— Apparent  absence  of  intellectual  disorder  and  pro- 
nounced mental  disease  not  incompatible — Simulation  and  dis- 
simulation— Confession  of  feigned  insanity — Expert  observation 
necessary  in  every  instance  of  suspected  crime — Family  history 
and  previous  life  most  important. 

A.  Anamnesis.  (Previous  History.)  .  .  .  102 
Hereditary  taint — Family  history — Central  office  for  the  preser- 
vation of  records — Value  of  ancestral  charts  for  the  science  of 
criminology — The  Mendelian  theory  as  applied  to  man — The 
forms  of  heredity — The  patient's  previous  history — Surround- 
ings and  antecedents — History  of  development  of  the  disease  un- 
der consideration — Alteration  of  personality. 

B.  Observation  of  the  Patient 108 

The  first  meeting  between  physician  and  patient — Observation 
of  itself  most  important;  facial  expression;  posture  and  ges- 
tures; simulants  as  psychopaths;  objective  symptoms  that  con- 
firm the  existence  of  sense  deceptions — Care  or  neglect  of  the 
body  as  a  measure  of  mental  disturbance — The  physiognomy  of 
the  insane — Degenerative  signs — Disturbance  of  nutrition — Tem- 
perature, pulse  and  blood  pressure — Secretions  and  excretion — 
Sleep — Speech  and  handwriting. 

C.  Physical  Examination 

1.  Anatomic-physiologic  relations         .        .        .     120 

Zoological  procedure  in  psychiatry — Lombroso  and  the  congeni- 
tal criminal — The  doctrine  of  degenerative  stigmata — The  con- 
formation of  the  skull — Cranial  measurements — The  hair,  the 
teeth,  the  external  ear,  the  eyes,  the  extremities,  the  build  of 
the  body — The  relations  of  such  signs  of  degeneracy  to  men- 
tal disorder — Examination  of  the  internal  organs — Disorders  of 
function — Blood  and  spinal  fluid  examination — Sero-diagnosis — 
Sexual  excitability — Body  weight — Pulse,  temperature  and  urine. 

2.  The  Nervous  System  .  .  .  .  .  128 
Pupillary  disorder — "Weakness  of  ocular  muscles — The  speech  and 
the  voice — Mutism — The  handwriting — Ophthalmoscopic  exami- 
nation— Test  of  the  reflexes. 

D.  Testing  the  Mental  Behavior       ....     132 

Orientation  —  Confusion — Delusions  and  disorientation  —  Ex- 
amples showing  the  relations  that  obtain  between  orientation  and 
the  psychoses — The  diagnostic  value  of  an  accurate  orientation 
test — The  importance   of   an   anamnesis   as   obtained   from   the 


x  CONTENTS 

PAGE 

patient  himself — Sense  deceptions — Illusions — Hallucinations — 
Delusions — Relative  diagnostic  value  of  the  different  kind  of  de- 
lusions; their  occurrence  and  significance  in  the  various  dis- 
eases— Association  tests — Statistic  method,  Binet-Simon  test,  etc. 
— The  information  obtained  through  intelligence  tests. 

3.  Delusions 151 

4.  The  Memory 161 

The  examination  of  the  memory,  intelligence  and  judgment — 
The  memory  for  the  more  distant  past,  the  memory  for  recent 
events — Disorders  of  the  faculty  of  recollection — Amnesia — The 
transmutations  of  paranoiacs — Confabulations — Conscious  con- 
fabulations and  the  false  accusations  of  epileptics  and  alco- 
holics. 

5.  The  Intelligence  and  Judgment        .        .        .    173 
Memory  test  and  intelligence  test  to  be  sharply  held  apart. 

Part  Second:    Psychiatric  Expertism. 

Special  Diagnostics  of  Mental  Disorders. 

I.      PSYCHOSES  IN  GENERAL 

1.  Paresis 183 

Its  syphilitic  origin  and  importance  of  early  recognition;  symp- 
tomatology— Diagnostic  value  of  nerve  symptoms  when  asso- 
ciated with  mental  changes,  pupillary  disturbances,  disordered 
reflexes,  and  speech  anomalies — Psychic  symptoms — Division  into 
four  classes. 

A.  The  demented  form  of  paresis  ....  188 
Differential  diagnosis  from  neurasthenia,  brain  syphilis,  focal 
brain  disease,  senile  dementia. 

B.  The  depressive  form  of  paresis  ....  191 
Differential  diagnosis  more  especially  from  melancholia  and 
paranoia. 

C.  The  expansive  form  of  paresis  ....  193 
Differential  diagnosis  in  the  absence  of  somatic  symptoms  often 
not  possible;  from  circular  insanity. 

D.  The  agitated  form  of  paresis  ....  194 
Its  differentiation  from  other  maniacal  states — Forensic  as- 
pects. 

2.  Dementia  praecox 196 

Characteristics — Division  into  three  forms,  symptomatology, 
course  and  outcome — Differential  diagnosis  from  hysteria,  epi- 
lepsy, neurasthenia,  manic  depressive  insanity. 


CONTENTS  xi 

PAGE 

A.    Dementia  prcecox  simplex    .....    197 


B.  Dementia  prcecox  paranoides  ....  203 
Symptomatology  and  course — Early  onset  of  paranoid  delusions 
— Delusions  of  grandeur — Preservation  of  memory — Differential 
diagnosis  from  hallucinatory  confusion,  paranoia,  dementia  para- 
lytica. 

C.  Dementia  prcecox  katatonica  ....  206 
Relatively  small  importance  of  sense  disturbances — Onset,  symp- 
tomatology and  course — Differential  diagnosis,  from  mania,  de- 
mentia paralytica,  hysteria,  epilepsy,  katatonia — Forensic  aspects. 

D.  Katatonia 212 

Similarity  between  it  and  dementia  preeeox  katatonica;  differ- 
ence in  course  necessitates  special  classification. 

3.  Acute  hallucinatory  confusion  ....  213 
Its  interpretation — Differential  diagnosis  from  the  delirium  of 
fever  and  infections,  alcoholic  intoxication,  epilepsy,  dementia 
praecox  paranoides,  mania,  katatonia. 

4.  Hallucinatory  insanity 217 

Its  interpretation,  symptomatology  and  course — Differential 
diagnosis  from  alcoholic  insanity,  cocainism,  paranoia,  melan- 
cholia, epilepsy,  dementia  paralytica. 

5.  Paranoia 219 

Its  primary  character;  its  system  of  delusions — A  disease  of  the 
entire  personality — Origin  and  development  of  the  systematiza- 
tion — Its  psychological  nucleus — Symptomatology  and  course — 
Delusions  and  hallucinations — Varieties  of  the  disease — Forensic 
aspects — Differential  diagnosis  from  dementia  praecox  para- 
noides, dementia  paralytica,  manic  depressive  insanity,  dementia 
senilis,  pre- senile  delusional  insanity. 

A.  Mania 229 

Definition  and  interpretation — Symptoms  and  course — Differen- 
tial diagnosis  from  dementia  paralytica,  dementia  prascox,  acute 
hallucinatory  insanity,  agitated  melancholia — Forensic  aspects. 

B.  Melancholia 234 

Its  characteristics  and  their  interpretation;  symptomatology  and 
course — Early  development  of  delusions — The  melancholiae  as  a 
persecute  passif — Sense  deceptions;  persistent  attempts  at  self- 
destruction — Varieties — Prognosis — Forensic  aspects — Differen- 
tial diagnosis  from  dementia  paralytica,  senile  dementia,  par- 
anoia, manic  depressive  insanity. 


xii  CONTENTS 

PAGE 

C.     Manic  depressive  insanity 243 

Its  interpretation;  the  manie  phase;  the  depressive  phrase; 
mixed  states — Forensically  the  disease  often  represents  a  con- 
tinuous or  permanent  state — Differential  diagnosis — Forensic  as- 
pects. 

II.      THE  NEUROPSYCHOSES 

1.  Hysteria 250 

Interpretation;  factors  essential  for  diagnosis;  the  hysterical 
personality — Development  of  the  symptoms  of  hysteria  upon  the 
permanently  abnormal  state — The  most  important  bodily  disor- 
ders—Hysterical insanity  in  a  more  restricted  sense — Differen- 
tial diagnosis  from  all  possible  diseases  of  the  brain  and  spinal 
cord;  from  a  series  of  other  psychogenic  disorders.  Forensic 
aspects. 

2.  Neurasthenia 260 

Interpretation,  symptomatology  and  course — Forensic  aspects — 
Differential  diagnosis. 

3.  Psychic  constitutional  inferiority  .  .  .  263 
Hereditary  taint  as  manifested  by  certain  psychic  anomalies — 
Psychopathic  inferiority — The  manifestations  of  constitutional 
inferiority  in  early  childhood — Early  sexual  desires  and  traits; 
the  adult  psychopath;  the  emotional  form  of  constitutional 
inferiority;  bodily  abnormalities — Forensic  aspects. 

4.  Epilepsy 266 

Symptomatology — The  convulsive  attacks;  psychic  disorders — 
Course — Prognosis — Differential  Diagnosis — Forensic  aspects. 

5.  Chorea 275 

Psychic  anomalies — Actual  psychoses — Huntington's  chorea — 
Differential  diagnosis. 

m.      THE  PSYCHOSES  OP  INVOLUTION 277 

1.  Dementia  senilis 277 

Definition,  symptomatology  and  course;  differential  diagnosis 
from  paresis,  melancholia,  the  pre-senile  paranoid  state,  manic 
depressive  insanity,  hallucinatory  confusion — Forensic  aspects. 

2.  Pre-senile  paranoid  insanity  ....  282 
Symptomatology  and  course — Differential  diagnosis  from  para- 
noia, beginning  senile  dementia,  paresis. 

3.  Hystero-hypochondriasis 284 

Symptomatology  and  course — Differential  diagnosis  from  hys- 
teria, melancholia,  paranoia. 


CONTENTS  xiii 

PAGE 

IV.      THE  INTOXICATION  PSYCHOSES 

1.  Alcoholism 288 

Manifestations — Classification  of  pathological  effects. 

A.  Pathological  states  of  inebriety  ....  288 
Definition;  occurrence  upon  a  psychopathic  constitutional  basis 
— Its  great  forensic  import. 

B.  Delirium  tremens 289 

Definition;  phases  of;  typical  features — Prognosis — Differential 
diagnosis  from  the  delirium  of  epilepsy,  the  delirium  with  men- 
ingitic  symptoms. 

C.  Acute  hallucinosis  of  drinkers  ....  293 
Definition,  symptoms  and  course — Differential  diagnosis. 

D.  Korsakoff's  psychosis    ......    294 

Polyneuritic  psychosis — Development,  symptomatology  and 
course — Differential  diagnosis  from  dementia  paralytica,  de- 
mentia senilis. 

E.  Chronic  alcoholism 297 

Psychotic  characterization — Diagnosis  and  prognosis — Differen- 
tial diagnosis — Forensic  aspects  of  the  different  alcoholic  psy- 
choses. 

F.  Alcoholic  paranoia 299 

2.  Morphinism 301 

Symptomatology  and  course — Diagnosis. 

3.  Coeainism 303 

Symptomatology  and  course — Diagnosis. 

4.  Lead  Intoxication 305 

Classification,  symptomatology  and  course  of  the  psychoses  due 
to  lead  poisoning — Prognosis. 

Part  Third:    Special  Anomalies. 

i.    hypnosis 309 

The  term  hypnosis,  hypnotism  and  hypnotic  suggestion — Theoret- 
ical juristic  considerations — Historical  development  of  the  doc- 
trine of  hypnotism — Paracelsus,  Mesmer,  Faria  and  Braid ;  Char- 
cot and  Bernheim — The  Paris  school  and  its  doctrines — The  the- 
ory of  the  Nancy  school — The  practical  forensic  deductions  to 
be  drawn  from  their  teachings — Does  hypnosis  possess  any  spe- 
cial characteristic  symptomatology? 

II.      THE  ANOMALIES  OF  SEXUAL  SENSE  ....      328 

The  sexual  impulse  in  its  anthropological  and  sociological  rela- 
tions^— The  judicial  appraisal  of  sexual  delicts  solely  by  objec- 


xiv  CONTENTS 

PAGE 

tive  conditions — Historical  reflections — Anomalies  not  necessarily 
pathological — Classification  of  sexual  perversions. 

1.  Anachronistic  anomalies    ......    332 

2.  Quantitative  anomalies 332 

3.  Qualitative  anomalies        .....    334 

A.  Heterosexual  anomalies 335 

Coitus  associated  with  non-essential  acts — Coitus-like  acts — Sex- 
ual symbolism — Sexual  Fetishism — Laseiviencies;  frotteurs,  ex- 
hibitionists and  voyeurs — Algolagnia — Sadism — Masochism. 

B.  Homosexual  anomalies,  congenital  and  acquired  347 
Their  psychopathological  significance.  The  treatment  accorded 
the  anomalies  of  sexual  sense  under  the  various  systems  of  puni- 
tive law. 

Scope  of  the  expert  opinion  in  forensic  psychiatry — The  Judge 's 
estimation  of  the  expert's  exposition — The  application  of  the 
physician's  knowledge  to  questions  of  law — The  selection  of  ex- 
perts— The  contents  of  an  expert  opinion. 

practical    examples    illustrative    op    expert 
opinions 359 

Literature 405 

Index 413 


THE  UNSOUND  MIND  AND  THE  LAW 


INTRODUCTION 

All  treatises  on  legal  medicine  lay  stress  upon  the  physician's 
need  of  acquainting  himself  intimately  with  the  relevant  laws 
and  their  juristic  interpretation.  "While  I  recognize  the  value 
of  juristic  knowledge  on  the  part  of  the  physician  who  is  called 
upon  for  an  expert  opinion,  and  that  he  must  understand  the 
principles  upon  which  the  law  is  based  so  that  he  may  the  more 
easily  comply  with  its  demands,  I  must  emphatically  maintain 
the  existence  of  an  unavoidable  moral  obligation  on  the  part  of 
the  jurist  to  equip  himself  with  a  proper  understanding  of  the 
principles  underlying  the  expert  opinion  of  the  physician.  I 
can  readily  understand  that  a  medical  expert  in  his  own  field 
may  give  a  faultless  opinion,  in  thorough  accord  with  scientific 
views,  although  he  may  lack  a  knowledge  of  the  existing  laws, 
but  I  cannot  comprehend  how  a  jurist  entirely  unfamiliar  with 
the  domain  of  thought  that  governs  medicine  and  the  natural 
sciences  can  form  a  correct  opinion  regarding  questionable 
states  of  mental  disorder. 

Some  years  ago  I  called  attention  to  the  insufferable  contra- 
dictions that  existed  between  our  so  frequently  antiquated  legal 
enactments  and  modern  psychiatry.  I  laid  stress  upon  the  pos- 
sibility that  a  person  who  had  committed  a  criminal  act  while 
under  the  bane  of  a  morbid  impulse  of  the  will  might  be  legally 
convicted,  because  the  law,  while  it  accorded  an  exculpatory 
value  to  abnormal  intellectual  activity,  dealt  otherwise  with  dis- 
orders that  implicated  the  activity  of  the  will.  I  need  hardly 
say  that  if  under  such  conditions  the  judge  insisted  upon  the 
letter  of  the  law  and  turned  a  deaf  ear  to  all  psychiatric  reason- 
ing, even  the  most  intimate  knowledge  of  the  law  could  not  help 
the  physician  in  the  slightest  degree.  While  it  must  be  ad- 
mitted that  the  judge  can  but  apply  and  enforce  the  law  as  it 
exists,  and  may  not  render  a  decision  that  is  solely  in  accordance 
with  his  moral  conviction  and  with  ordinary  common  sense,  all 
application  of  existing  laws,  no  matter  how  inadequate  they 

3 


4   THE  UNSOUND  MIND  AND  THE  LAW 

may  be  in  themselves,  must  to  a  great  extent  be  a  question  of 
interpretation.  The  judge  who  is  conversant  with  the  funda- 
mental principles  of  psychiatry  will  necessarily  interpret  these 
laws  differently  from  the  jurist  who  disregards  the  law's  spirit 
and  purpose  and  adheres  exclusively  to  its  letter.  It  should  be 
the  endeavor  of  the  judge  to  prevent  injustice,  to  thwart  the 
punishment  of  the  innocent,  and  to  frustrate  the  escape  of  the 
guilty.  The  object  of  the  physician  who  testifies  in  court 
should  be  no  different,  and  it  is  this  common  purpose  that  im- 
poses upon  the  physician  the  duty  of  acquiring  adequate  jur- 
istic knowledge,  and  upon  the  jurist  the  obligation  to  instruct 
himself  in  regard  to  such  facts  in  medicine  and  the  natural 
sciences  as  are  of  importance  in  the  field  we  are  now  con- 
sidering. 

While  a  physician's  testimony  concerning  injuries  to  health, 
or  regarding  death  due  to  violence,  as  well  as  his  testimony  in 
mooted  sexual  matters,  may  be  restricted  to  the  actual  facts,  his 
task  when  testifying  concerning  doubtful  states  of  mental  dis- 
ease will  necessarily  be  of  a  more  involved  nature.  After  the 
actual  facts  in  such  cases  have  been  ascertained,  the  question 
whether  the  person  who  has  committed  the  punishable  deed  is 
responsible  for  his  act  remains  to  be  answered — in  other  words, 
it  must  be  determined  whether,  at  the  time  of  commission,  his 
will  was  free,  or  whether,  in  consequence  of  mental  confusion 
or  clouded  consciousness,  the  free  exercise  of  his  will  was 
restricted  or  entirely  annulled,  so  that  the  inhibitory  concepts 
normally  present  could  not  be  called  into  action.  Even  if  the 
absence  of  conscious-inhibitory  motives  could  not  be  assumed, 
there  might  still  be  a  question  whether,  being  present,  their 
influence  had  not  been  counteracted  by  an  uncontrollable  obses- 
sion. If  this  were  so,  we  would  be  confronted  by  the  existence 
of  a  condition  in  which,  notwithstanding  his  recognition  of  the 
wrongfulness  and  punishability  of  an  act,  the  individual  could 
not  be  held  responsible,  because  the  act  was  the  product  of  dis- 
ordered activity  of  the  will. 

Moreover,  we  must  consider  that  the  courts  are  occasionally 
misled  so  as  to  confound  adept  simulation  with  mental  disease, 
or,  what  is  more  frequent,  to  accept  skilful  dissimulation  for 
mental  health.  Finally,  it  is  not  unusual  for  the  courts  to  be 
led  astray  by  the  self-accusations  of  persons  who  are  insane,  and 


INTRODUCTION  5 

much  valuable  time  may  be  sacrificed  before  the  incorrectness  of 
the  seemingly  trustworthy  self-accusation  can  be  demonstrated. 
Should  such  deceptions  or  errors  not  be  controverted,  the  judge 
may,  against  his  will,  be  placed  in  the  position  of  having 
thwarted  the  intent  of  the  law,  and  of  punishing  an  innocent 
or  irresponsible  person  or  freeing  a  guilty  one.  Or,  where  there 
is  no  question  of  a  punishable  act  but  solely  one  of  competency 
in  commercial  matters,  or  of  the  existence  of  a  mental  disorder 
that  precludes  all  free  determination,  the  judge  may  involun- 
tarily assist  a  squanderer,  an  alcoholic,  or  a  morphinist  in  bring- 
ing economic  destruction  upon  his  family,  or  an  insane  person 
who  is  a  menace  to  himself  and  his  surroundings  in  retaining 
his  freedom. 

When  a  judge  does  not  know  that  morbid  disturbances  of 
mental  activity  may  affect  in  one  instance  the  perceptual  sphere, 
in  another  the  emotional  life,  and  in  still  another  the  will  power, 
when  he  does  not  know  that,  in  conformity  with  scientific  views, 
responsibility  may  not  only  be  entirely  but  also  partially  an- 
nulled, he  will  be  inclined  to  decide  the  question  of  the  existence 
of  mental  disorder  in  accordance  with  the  principle  that  a  person 
must  be  either  insane  and  irresponsible  or  entirely  sane  and 
responsible.  Then,  if  he  is  to  decide  a  case  in  which,  for  in- 
stance, the  intellect,  the  power  of  ideational  association  and  of 
logical  thought,  is  apparently  unimpaired,  or  in  which  disorder 
of  the  emotion  and  of  the  will  happens  to  be  undemonstrable, 
the  judge  will  be  but  too  prone  to  assume  the  existence  of  mental 
health  and  to  deny  an  application  for  the  appointment  of  a 
guardian,  or  one  for  a  commitment  to  an  institution.  In  so 
doing  he  may  well  be  governed  by  the  consideration  that  it  is  a 
serious  matter  to  deprive  of  his  liberty  a  person  who  has  com- 
mitted no  punishable  act  and  who  has  the  appearance  of  being 
mentally  healthy.  Possibly,  also,  he  may  be  influenced  by  the 
knowledge  that  schemes  to  rid  themselves  of  an  inconvenient 
member  of  a  family  are  not  infrequently  undertaken  by  rela- 
tives and  aided  by  unscrupulous  members  of  the  legal  and 
medical  professions. 

We  can  see,  therefore,  that  an  inexperienced  judge,  notwith- 
standing that  his  intentions  may  be  of  the  best,  may  bring  about 
the  very  reverse  of  that  which  he  and  the  law  intend.  Were 
the  determination  of  the  existence  of  mental  disorder  in  ques- 


6   THE  UNSOUND  MIND  AND  THE  LAW 

tionable  instances  dependent  upon  the  judge  alone,  many  guilty 
persons  would  escape  punishment,  while  many  insane  and  irre- 
sponsible ones  would  suffer  undeserved  penalties. 

It  is  obvious,  therefore,  that  the  judge  must  be  aided  by  expert 
advice.  The  cry  that  psychiatrists  believe  it  proper  to  aid 
guilty  persons  to  escape  merited  punishment  by  endeavoring  to 
prove  them  insane  is,  of  course,  unjust.  In  giving  an  expert 
opinion  concerning  states  of  doubtful  mental  disorder,  the 
conscientious  psychiatrist,  no  less  than  the  judge,  is  governed 
by  an  interest  in  the  public  welfare,  and  even  when  he  is  un- 
familiar with  the  text  of  the  law,  he  carries  out  its  intent  by 
determining  whether  mental  integrity,  limited  responsibility  or 
complete  irresponsibility  exists.  Whether  the  judge,  solicitous 
of  applying  the  law  in  accordance  with  its  spirit,  will  be  satisfied 
with  the  statement  of  the  psychiatrist  and  decide  accordingly,  is 
quite  another  question.  If,  however,  the  judge  renders  a  de- 
cision that  is  contrary  to  the  physician's  conscientious  and 
scientifically  correct  testimony,  the  physician  certainly  must  be 
absolved  from  all  responsibility.  Certainly  the  physician  need 
not  endeavor  to  adapt  his  expert  opinion  to  the  existing  laws. 
Where  these  laws  are  the  expression  of  antiquated  views  which 
cannot  possibly  be  made  to  conform  with  the  views  of  modern 
psychiatry,  any  agreement  with  them  could  but  be  specious  and 
sophistical.  In  my  opinion  it  is  more  important  that  the 
antiquated  laws  bearing  on  doubtful  mental  disorders  be  so 
modified  that  they  will  conform  to  the  teachings  of  modern 
psychiatry. 

The  physician  is  bound  by  the  teachings  of  science,  and  the 
crass  antagonism  between  these  teachings  and  the  antiquated 
views  of  the  law  that  so  often  manifests  itself  can  but  exert  a 
beneficial  and  modernizing  influence  upon  the  interpretation  of 
the  laws  as  they  exist.  This  becomes  the  more  evident  when 
we  consider  that,  after  all,  it  is  upon  the  lay  judges  (the  jury) 
and  not  upon  the  professional  judge  that  the  decision  of  guilt 
or  innocence  devolves ;  and  in  forming  an  opinion  they  as  a  rule 
will  be  governed  less  by  the  letter  of  the  law  than  by  ordinary 
common  sense,  and,  therefore,  will  be  more  easily  influenced 
by  the  arguments  of  the  psychiatric  expert.  How  each  indi- 
vidual case  may  be  affected  by  the  interpretation  that  is  given  to 
the  law  is  shown  by  the  fact  that,  while  according  to  the  existing 


INTRODUCTION  7 

statutes  in  certain  states,  an  attempt  at  suicide  is  a  punishable 
offense,  it  is  most  rarely  punished,  even  in  the  absence  of  any 
suspicion  of  mental  disorder. 

I  have  already  indicated  that  the  psychiatrist  who  gives  his 
expert  opinion  in  accordance  with  scientific  principles,  but 
without  considering  the  wording  of  the  law,  deals  more  fairly 
with  the  law  than  does  the  judge  who  decides  according  to  the 
letter  of  the  law  without  having  any  interest  in  or  any  under- 
standing of  psychiatric  knowledge.  Why  is  it  that  judges  are 
so  often  led  astray  by  simulants  and  dissimulants  and  that  the 
mental  condition  of  an  accused  person,  even  when  he  makes  no 
attempt  at  voluntary  deception,  is  but  infrequently  correctly 
understood  by  the  members  of  the  legal  profession?  Why  is  it 
that  psychiatry,  which  could  and  should  be  of  so  great  aid  to 
the  jurist,  is  as  yet  inadequately  appreciated  by  judges  and 
lawyers  ? 

The  answer  to  these  questions  is  that  all  laymen — and  jurists 
are  laymen  in  this  regard — notwithstanding  all  efforts  to  en- 
lighten them,  still  remain  entirely  ignorant  concerning  mental 
disease  and  are  prejudiced  against  occupying  themselves  in  any 
way  with  the  questions  it  involves.  This  antipathy,  which  to 
some  extent  has  been  fostered  by  the  difficulties  involved  in  a 
study  and  an  understanding  of  the  anatomical,  physiological 
and  pathological  relations  of  the  brain,  is  not  merely  one  in 
theory,  but  actually  extends  to  the  mentally  disordered  persons 
themselves,  to  the  insane  asylums,  to  their  physicians  and  at- 
tendants. Moreover,  strange  as  it  may  appear,  there  are  many 
medical  practitioners,  otherwise  skilful  and  well  informed,  who 
lack  all  understanding  of  and  often  are  entirely  ignorant  of  the 
inferences  which  psychoses  and  psycho-neuroses  have  upon  the 
patient's  life  and  surroundings.  That  the  insane  should  be 
regarded  in  the  same  way  as  persons  who  are  physically  sick, 
except  that  in  the  one  instance  the  lungs,  kidneys,  stomach, 
heart,  etc.,  are  implicated,  while  in  the  other  it  is  the  brain  and 
nervous  system  that  are  particularly  affected,  is  a  truth  which, 
although  constantly  taught  and  reiterated,  does  not  yet  seem 
to  be  fully  understood.  Even  at  the  present  time  there  exists 
among  the  ignorant  masses  a  belief  in  demonic  possession  as  a 
cause  of  mental  disease,  even  to-day  Pharisaic  and  censorious 
cavilers  look  upon  such  disease  as  a  punishment  for  a  sinful 


8       THE  UNSOUND  MIND  AND  THE  LAW 

mode  of  life;  even  to-day  there  are  numerous  persons  who, 
though  vaunting  their  enlightened  intelligence,  assume  the 
existence  of  a  spiritual  world  supposed  to  be  governed  by  other 
laws  than  the  laws  of  nature  which  govern  the  material  world, 
and  in  which,  therefore,  diseases  of  the  mind  supposedly  de- 
velop independently  of  the  functions  of  the  brain  or  of  the  dis- 
eases of  the  body.  All  of  which  shows  that  our  present  era, 
often  so  boastful  of  its  freedom  from  prejudice,  has,  as  a 
matter  of  fact,  merely  exchanged  old  prejudices  for  new  ones. 

We  should  look  upon  every  person  who  is  mentally  disordered 
as  a  fellow  being  who  is  sick,  as  one  who  has  a  claim  upon  our 
compassion  and  requires  our  aid — particularly  so  because  his 
highest  faculties  have  become  clouded  or  destroyed. 

Even  if  it  were  the  case  that  careful  examinations  of  the 
brains  of  the  insane  should  reveal  no  disorder  of  their  structure, 
there  could  nevertheless  be  no  doubt  that  gross  or  minute  dis- 
turbances of  the  brain  substalice,  changes  of  its  chemical  com- 
position, variations  in  the  circulation  of  the  blood  and  lymph 
(congestion,  anemia,  stasis),  nutritional  disturbances  of  the 
brain  or  its  membranes  and  its  blood  vessels,  must  be  held  re- 
sponsible for  the  causation  of  alterations  in  the  mental  functions, 
no  matter  whether  these  manifest  themselves  merely  as  anom- 
alies of  emotion,  will  power  or  consciousness,  or  as  sense  de- 
ceptions and  delusions.  As  a  matter  of  fact,  however,  in  a  large 
number  of  states  of  mental  disorder  actual  anatomical  brain 
changes  may  be  positively  and  directly  recognized — either  with 
the  naked  eye  or  by  means  of  the  microscope.  This,  for  in- 
stance, is  true  in  arrested  brain  development,  in  idiocy  and 
cretinism,  in  senility  and  pronounced  dementia,  in  paresis  and 
in  certain  cases  of  epilepsy.  It  is  quite  probable  that  the  in- 
creasing improvement  in  our  technical  methods  and  means  of 
examination  ultimately  will  enable  us  also  to  recognize  those 
more  minute  structural  changes  of  the  brain  tissue  which  have 
until  now  escaped  our  notice ;  and  then  the  mutational  relation- 
ship existing  between  brain  and  mind,  physiologically  as  well  as 
pathologically,  will  be  fully  revealed. 

It  is  a  fact  that  there  can  be  no  mental  activity,  normal  or 
abnormal,  that  is  independent  of  the  brain.  Likewise,  it  is  a 
fact  that  in  most  instances  psychoses  are  caused  by  bodily  dis- 
eases which  implicate  the  brain  and  nervous  system,  and  purely 


INTRODUCTION  9 

psychic  injuries  unaccompanied  by  bodily  manifestations  of 
disease  are  of  etiological  moment  only  in  the  most  exceptional 
instances.  In  this  connection  we  should,  however,  consider  that 
in  those  cases  in  which  mental  disorder  is  a  sequence  of  the 
bodily  disease,  the  bodily  disorder  has  usually  passed  away  and 
the  mental  disorder  apparently  stands  alone,  having  no  con- 
nection with  any  organic  somatic  changes.  To  a  great  extent 
this  explains  the  different  points  of  view  maintained  by  the 
laity  and  even  by  the  cultured  jurists  toward  disease  of  the 
body  and  disease  of  the  mind.  The  former  is  never  regarded 
without  concern  and  is  considered  a  misfortune  deserving  sym- 
pathy and  interest;  a  psychosis,  however,  though  often  depend- 
ent upon  the  very  same  cause,  is  usually  looked  upon  as  some- 
thing reprehensible.  Although  the  ordinary  mind  will  compre- 
hend a  delirium  in  a  person  suffering  from  pneumonia  or  typhoid 
fever  and  understand  its  manifestation  to  be  dependent  upon 
the  associated  bodily  disease  and  the  coexisting  fever,  although 
everybody  will  recognize  that  alcoholism  manifested  as  delirium 
is  the  natural  result  of  alcoholic  excesses  and  will  in  no  way  be 
astonished  by  its  occurrence,  it  is  common  to  misinterpret  or 
not  to  understand  the  states  of  pure  mental  disorder  when  they 
are  unassociated  with  noticeable  physical  faults,  even  when  their 
manifestations  are  similar  to  those  of  a  delirium  or  when  they 
have  developed  from  a  clearly  physical  basis. 

While  no  one  would  think  of  considering  a  delirious  patient 
of  this  type  sensible  and  responsible,  it  is  often  believed  to  be 
not  only  possible,  but  right,  to  associate  and  to  argue  with  him 
as  though  he  were  in  perfect  health.  His  actions  are  ascribed 
to  the  same  motives  as  those  which  obtain  under  similar  con- 
ditions in  normal  persons,  and  he  is,  therefore,  expected  to  re- 
spond to  appeals  and  arguments  like  a  person  in  mental  health. 
Therefore,  it  often  follows  that,  because  the  morbid  causality  is 
not  recognized  in  the  expressions  and  actions  of  the  insane,  they 
are  not  believed  to  be  sick,  and  their  actions  are  supposed  to  be 
the  results  of  obstinacy,  craftiness  and  malevolence;  or  else 
recourse  is  had  to  the  other  extreme,  and  the  patient  is  looked 
upon  as  a  person  totally  bereft  of  intelligence,  emotion  and  will 
power,  as  one  who  is  dominated  by  mysterious  forces  and  who 
can  be  compared  only  with  an  infant,  or  even  with  an  animal. 
This  explains  the  opprobrium  which  even  at  present  is  attached 


10       THE  UNSOUND  MIND  AND  THE  LAW 

so  frequently  to  mental  disease,  and  it  also  explains  the  numer- 
ous errors  which  lawyers  commit  when,  without  any  knowledge 
of  fundamental  psychiatric  principles,  they  rely  essentially  upon 
their  natural  powers  of  observation  for  the  estimation  of  ques- 
tionable or  borderline   mental   states. 

By  "questionable"  states  of  mental  disorder  I  mean  all  those 
psychic  manifestations  as  to  which  it  is  uncertain  whether  they 
are  the  product  of  normal  or  abnormal  brain  activity.  A  priori 
this  can  never  be  decided.  The  man  who  possesses  histrionic 
talent  and  has  at  his  command  such  thorough  skill  as  Shake- 
speare must  have  possessed  will  perhaps  be  able  to  simulate 
insanity  with  its  physical  accompaniments  to  such  perfection 
that  even  physicians  will  be  deceived.  Hence,  when  in  a  court 
procedure  the  defendant  rolls  his  eyes,  talks  confusedly,  goes 
into  convulsions,  etc.,  it  is  well  first  to  think  whether  it  may  be 
a  well  acted  comedy,  and  only  after  this  possibility  can  be  ex- 
cluded with  certainty,  to  consider  the  existence  of  actual  mental 
disease.  On  the  other  hand,  it  is  easy  to  conceive  that  a  patient 
who  from  a  psychiatric  standpoint  is  undoubtedly  insane  may 
appear  to  be  mentally  normal  to  the  jurist.  Thus,  for  instance, 
it  is  quite  possible  that  the  existence  of  morbid  ideas  may  not 
be  discovered  because  they  have  been  purposely  concealed.  So 
long  as  the  patient  knows  it  is  considered  a  disgrace  to  suffer 
from  mental  disorder,  so  long  as  his  over-sensitive  mind  is  ob- 
sessed by  the  fear  of  maltreatment  in  asylums,  it  will  be  natural 
for  him  to  rebel  against  being  pronounced  mentally  sick, 
especially  when  he  realizes  the  diagnosis  may  carry  with  it  a 
declaration  of  incompetency,  a  deprivation  of  liberty  and  social 
ostracism.  Naturally  he  will  not  recognize  that  an  internment  in 
a  sanatorium  is  for  his  own  good,  consequently  he  will  endeavor 
to  suppress  those  manifestations  of  mental  activity  which  he 
knows  will  be  looked  upon  as  morbid,  and  sometimes  he  will 
do  this  so  successfully  that  the  judge  will  be  influenced  to  decide 
against  the  appointment  of  a  guardian  or  an  internment  in  an 
institution.  Similarly,  even  where  there  exists  no  intent  to 
deceive,  the  person  whose  sanity  is  being  investigated  may  be 
declared  sane  by  the  judge,  while  the  experienced  psychiatrist 
will  without  difficulty  recognize  the  existence  of  a  morbid  state 
of  mental  activity  which  precludes  all  free  determination  of 
the  will, 


INTRODUCTION  11 

The  difficulties  surrounding  the  legal  appreciation  of  doubtful 
cases  of  mental  disorder  are  produced  not  only  by  simulation 
and  dissimulation,  but  are  in  great  part  due  to  the  existence  of 
mental  states  occupying  the  borderline  between  health  and  dis- 
ease, borderline  states  in  which  responsibility  exists  in  one  direc- 
tion, while  irresponsibility  is  present  in  another.  Moreover,  we 
must  bear  in  mind  the  existence  of  those  apparently  free  inter- 
vals which  form  part  of  the  periods  of  manic-depressive 
psychosis,  of  the  prolonged  remissions  in  paresis,  and  of  the 
periods  in  epilepsy  during  which  no  convulsion  occurs.  If  the 
jurist  possesses  no  information  regarding  the  previous  history 
of  individuals  thus  afflicted,  the  impressions  he  obtains  of  them 
will  depend  entirely  upon  whether  they  happen  to  be  in  a  state 
of  remission  or  one  of  relapse.  Just  as,  upon  the  one  hand,  not 
every  act  of  a  psychically  abnormal  individual  excludes  free 
determination  of  the  will,  so  upon  the  other  hand  the  capability 
of  recognizing  right  from  wrong  and  the  preservation  of  a 
knowledge  of  the  punishability  of  an  act  do  not  prove  the  exist- 
ence of  free  determination  of  the  will,  because  the  morbid  emo- 
tions, ideas  and  impulses  may  counteract  the  power  of  acting 
in  accordance  with  that  recognition  and  appreciation.  With 
these  facts,  of  course,  the  jurist  must  be  conversant. 

Physicians  and  jurists  have  always  been  somewhat  at  variance 
in  regard  to  the  question  of  responsibility.  This  diversity  of 
opinion  is  undoubtedly  due  to  the  point  of  view  from  which 
the  subject  is  regarded.  The  physician  who  looks  upon  the 
mentally  disordered  individual  as  a  person  who  is  also  physically 
sick,  as  one  whose  mentality  is  implicated  in  consequence  of  dis- 
turbances of  bodily  function,  and  who  must  be  helped  by  remedy- 
ing these  disorders,  will  tend  to  lay  greater  stress  upon  the 
boundary  lines  of  the  mental  disorder  and  to  give  less  or  no  at- 
tention to  the  question  of  responsibility.  The  jurist,  on  the 
other  hand,  because  his  task  consists  in  the  recognition  of  cul- 
pability, finds  himself  obliged  to  restrict  the  confines  of  mental 
disorder  and  to  demand  an  establishment  of  a  sharp  line  of  de- 
marcation between  health  and  disease,  that  is,  between  those 
states  in  which  punishment  is  to  be  inflicted  and  those  in  which 
the  accused  is  to  be  considered  irresponsible.  Undue  emphasis 
upon  the  one  or  upon  the  other  point  of  view  must  be  discount 
tenanced. 


12   THE  UNSOUND  MIND  AND  THE  LAW 

Up  to  the  present  jurisprudence  has  started  from  the  premise 
that  delusions  constitute  the  basis  of  mental  disorder.  The  de- 
termining factor  has  always  centered  upon  the  question  whether 
the  accused  was  capable  of  recognizing  the  wrongfulness  and 
punishability  of  his  deed.  But,  as  the  physician  well  knows,  no 
delusion  ever  embraces  all  the  morbid  motives  that  directly  or 
indirectly  have  occasioned  the  commission  of  the  deed;  more- 
over, it  is  precisely  those  patients  who  have  the  finest  sense  of 
appreciation  of  right  and  wrong  that  suffer  most  from  morbid 
obsessions  which  run  counter  to  their  moral  principles.  On  the 
other  hand,  it  is  manifestly  unjust  to  declare  a  person  re- 
sponsible because  his  actions  are  apparently  not  based  upon  a 
delusion.  The  existence  of  a  delusion  is  by  no  means  requisite 
for  the  annulment  of  responsibility.  A  person  suffering  from 
acute  mania  may  have  killed  another  solely  in  consequence  of 
his  over-activity  and  feeling  of  physical  power,  and  while  some 
delusion  may  have  existed  at  the  same  time,  it  was  his  lack  of 
self-control  and  not  the  delusion  which  brought  about  the  catas- 
trophe. To  prove  that  this  loss  of  self-control  was  the  product 
of  disease  may  be  one  of  the  most  difficult  tasks  that  confront 
the  psychiatrist.  No  one  will  deny  that  an  epileptic  may  com- 
mit a  crime  because  he  has  lost  his  self-control,  for  just  before 
and  just  after  a  convulsive  seizure,  or  when  a  psychic  wave  takes 
the  place  of  a  seizure,  his  mind,  just  as  his  body  during  a  spell, 
is  entirely  beyond  control  of  his  will.  Other  states  also  may 
lead  to  imperative  acts,  which  cannot  be  suppressed  either  by 
external  influence  or  by  any  change  in  external  conditions. 

If,  then,  we  ask  under  what  conditions  this  loss  of  self-control 
represents  evidence  of  mental  disease,  and  under  what  condi- 
tions, on  the  other  hand,  it  should  be  considered  the  result  of  a 
state  that  the  individual  should  and  could  suppress,  the  reply 
may  be  most  complex.  In  certain  cases  loss  of  self-control  is 
caused  by  pure  weakness  of  will  power,  and  a  person  then  must 
be  held  responsible  if  he  consciously  exposes  himself  to  influences 
that  would  annul  his  self-control.  It  would  be  dangerous,  how- 
ever, to  admit  the  correctness  of  such  procedure  as  a  principle, 
for  it  is  clear  that  under  certain  conditions  the  slightest  frailty 
might  place  a  person  in  a  most  difficult  situation.  This  can  best 
be  illustrated  by  a  consideration  of  the  different  degrees  of  re- 
sponsibility in  the  various  stages  of  alcoholism. 


INTRODUCTION  13 

Let  us  take,  for  instance,  a  person  who  as  a  result  of  physical 
weakness  or  in  consequence  of  a  blow  on  the  head  received  at 
some  previous  time,  can  no  longer  tolerate  the  amount  of  alcohol 
that  he  had  been  accustomed  to  take  with  impunity,  and  who 
when  in  a  state  of  acute  alcoholism  commits  a  crime.  It  could 
hardly  be  held  that  such  a  person  was  fully  accountable  for  his 
acts.  On  the  other  hand,  if,  knowing  from  experience  that  he 
is  no  longer  able  to  stand  even  small  amounts  of  alcohol,  he  per- 
sists in  drinking  and  then  commits  an  unlawful  act,  he  must 
justly  be  considered  responsible  even  if  his  intolerance  to  alcohol 
be  the  result  of  inherited  taint  or  of  previous  injury.  Going 
still  further,  let  us  assume  that  in  consequence  of  continued 
alcoholic  excesses  he  gradually  becomes  mentally  disordered  and 
in  a  state  of  delirium  tremens  commits  a  crime.  Under  such 
conditions  he  can  be  adjudged  only  partially  responsible.  But 
if  the  alcohol,  instead  of  producing  a  delirium,  has  brought 
about  a  chronic  insanity  or  a  dementia,  and  in  the  persistent 
mental  confusion  of  such  states  he  comes  into  conflict  with  the 
law,  he  should  not  be  held  responsible  for  his  criminal  acts  even 
if  at  the  time  of  their  perpetration  he  was  but  slightly  or  even 
not  at  all  under  the  influence  of  an  alcoholic  stimulant.  This 
example  clearly  shows  how  complex  the  distinction  between  re- 
sponsibility and  irresponsibility  may  become. 

An  even  more  difficult  task  is  that  of  adjudicating  cases  of  so- 
called  impulsive  insanity,  a  state  in  which  a  patient  loses  his 
self-control  and  commits  an  act  which  he  recollects  in  all  its 
details,  but  from  which  he  truthfully  maintains  he  was  unable 
to  refrain.  Undoubtedly  such  morbid  impulses  independent  of 
all  delusions  or  illusions  do  occur.  Every  psychiatrist  has  been 
consulted  by  patients  who  have  told  him  that  such  loss  of  self- 
control  has  at  times  overwhelmed  them  like  a  storm  from  a  clear 
sky,  and  they  have  had  to  seek  some  place  of  safety,  to  flee  from 
themselves  as  it  were,  in  order  to  avoid  placing  themselves  or 
others  in  danger.  "When  such  morbid  impulses  do  occur  in  per- 
sons who  manifest  other  signs  of  insanity,  the  question  of  diag- 
nosis is  a  fairly  simple  one ;  but  when  the  existence  of  such  im- 
perative states  constitutes  the  sole  basis  for  the  diagnosis  of 
mental  disease,  the  difficulty  of  forming  a  decision  becomes  evi- 
dent. Moreover,  the  person  who  has  committed  a  crime  may, 
when  apprehended  or  when  he  surrenders  himself  voluntarily, 


14       THE  UNSOUND  MIND  AND  THE  LAW 

appear  perfectly  rational.  This  is  the  case  especially  with 
epileptics  and  patients  having  obsessional  impulses.  After  the 
emotional  outbreak  the  psychic  equilibrium  is  usually  re- 
established, and  it  seems  as  though  the  paroxysmal  discharge  has 
brought  about  at  least  a  temporary  restoration  to  health.  It  is 
then  very  difficult  to  make  the  lay  mind  understand  that  these 
acts  which  appear  to  have  been  carried  out  with  premeditation 
and  entire  reflection  have  been  perpetrated  in  a  state  of  trans- 
itory mental  disorder.  The  same  considerations  that  are  ap- 
plicable to  murderous  onslaught  also  obtain  in  regard  to  suicidal 
attempts,  to  sexual  crimes  and  other  imperative  acts.  Often  the 
outbreaks  are  followed  by  an  immediate  amelioration  of  the 
mental  state,  which  but  too  frequently  deceives  the  judge  as  to 
the  true  state  of  affairs. 

Later  on  we  shall  have  more  to  say  in  order  to  emphasize  the 
need  of  the  jurist  being  correctly  informed  concerning  the 
fundamental  psychic  principles  just  discussed.  But  it  is  also 
the  purpose  of  this  treatise  to  be  of  service  to  the  physician  who 
is  called  upon  to  give  an  expert  psychiatric  opinion  in  court,  and 
to  do  so  above  all  by  recalling  to  his  memory  those  considerations 
which  are  vitally  significant  for  the  forensic  estimation  of  doubt- 
ful states  of  mental  disorder. 

In  the  pathogeny,  the  clinical  picture,  the  prognosis  and  treat- 
ment of  mental  disease,  the  jurist  is  interested  only  in  so  far  as 
he  may  be  able,  by  their  aid,  to  obtain  a  clear  conception  of  the 
alteration  of  the  activity  of  the  will  which  the  diseased  men- 
tality may  have  produced.  He  desires  to  know  whether  in  the 
particular  case  there  exists  full  accountability,  partial  responsi- 
bility or  complete  abolition  of  free  determination  of  the  will ;  he 
desires  to  know  under  what  circumstances  the  activity  of  the 
intellect  and  of  the  will  run  in  parallel  lines,  under  what  condi- 
tions the  capacity  for  self-control  suffices  to  controvert  diseased 
impulses,  or  when  the  latter  will  be  stronger  than  the  corre- 
sponding inhibitory  concepts.  He  wants  to  know  to  what  extent 
a  person's  actions  will  be  influenced  by  delusions,  whether  it  is 
possible  for  a  person  of  intelligence  to  subdue  criminal  tenden- 
cies by  an  effort  of  the  will  and  whether  moral  deficiency  is 
necessarily  the  outcome  of  some  form  of  feeble-mindedness. 
Finally,  he  would  also  ask  whether  the  borderline  cases  of  in- 
sanity presented  for  the  court's  consideration  are  to  be  looked 


INTRODUCTION  15 

upon  as  transitory  or  permanent  states,  whether  they  may  be 
subject  only  to  partial  improvement  or  whether  complete  restitu- 
tion to  health  can  take  place.  For  the  jurist,  therefore,  every- 
thing centers  about  the  question  of  the  extent  to  which  the  legal 
relations  of  the  individual  toward  the  surrounding  world  are 
altered  by  insanity.  For,  according  to  law,  if  a  patient  is  un- 
able to  regulate  his  actions  in  conformity  with  intelligent  views, 
protection  must  be  given  by  relieving  him  of  the  legal  re- 
sponsibility ordinarily  attached  to  such  acts.  Similarly,  a 
patient  must  be  protected  against  the  punitive  consequences  of 
those  infractions  of  the  law  which  can  be  shown  to  be  the  prod- 
ucts of  diseased  activities  of  thought,  feeling  and  volition.  If, 
on  the  other  hand,  the  dependence  of  a  person 's  actions  upon  ab- 
normal brain  activity  cannot  be  proved,  that  person  must  be 
held  legally  responsible,  civilly  as  well  as  criminally,  for  all  the 
consequences  of  his  acts. 

I  have  already  indicated  the  points  that  are  important  in  a 
psychiatric  expert  opinion,  tending  in  the  one  instance  toward 
the  exposure  of  simulation  of  mental  disease,  and  in  the  other 
toward  indicating  so  forcibly  the  existence  of  actual  insanity 
that  the  judge  can  entertain  no  doubt  regarding  the  true  state 
of  facts.  To  determine  whether  a  person  is  entirely  deprived  of 
the  use  of  his  intellect,  or  whether  he  is  merely  incapable  of  ad- 
justing his  actions  to  the  demands  which  circumstances  make 
upon  him,  often  imposes  upon  the  expert  a  most  difficult  task, 
whose  fulfilment  requires  of  him,  above  all,  to  bear  in  mind  that 
the  determinative  factors  from  a  forensic  point  of  view  rest  not 
in  the  form  which  insanity  takes,  but  in  the  degree  of  the  mental 
disorder  or  the  consequence  which  it  entails.  It  would  be  as  im- 
proper for  the  physician  to  certify  the  existence  of  mental  health 
in  a  case  where  he  is  justified  only  in  maintaining  that  the  ex- 
amination has  revealed  nothing  pathological,  as  it  would  be  for 
him  to  attempt,  without  most  precise  knowledge  of  all  the  de- 
tails, to  diagnose  accurately  the  flowing  transitions  between  the 
normal  and  the  abnormal  in  indistinct  psychic  states. 

The  injury  that  may  be  done  to  a  good  cause  by  opinions 
based  upon  suppositions  and  probabilities,  or  by  over-enthusiasm 
on  the  part  of  the  physician,  will  be  considered  in  detail  further 
on.     It  has  been  my  desire,  just  at  this  place,  to  show  that  it  is 


16       THE  UNSOUND  MIND  AND  THE  LAW 

of  no  less  importance  for  the  jurist  to  understand  the  psy- 
chiatrist's point  of  view,  than  it  is  for  the  physician  to  construct 
his  psychiatric  testimony  so  as  to  conform  to  the  jurist's  stand- 
point and  to  do  so  with  full  consideration  for  the  purpose  and 
intent,  though  not  necessarily  for  the  letter  of  the  law. 


Part  First 

THE  GENERAL  RELATIONS  OF  JURIS- 
PRUDENCE  AND    PSYCHIATRY 


HISTORICAL  RETROSPECT 

Scientific  information  conveyed  in  the  form  of  accomplished 
facts  will  more  or  less  fail  to  be  understood  unless  the  source  of 
this  information  and  its  development  be  carefully  traced.  No 
knowledge  comes  to  us  as  a  revelation,  as  a  gift.  Everything  we 
wish  to  learn  must  be  acquired  through  earnest  mental  effort, 
through  accurate  observation  and  reflection.  At  first  the  notions 
that  lead  to  the  recognition  of  any  fact  are  rambling  and  mis- 
guided. Gradually  they  become  more  distinct  and  precise,  until 
finally  one  or  the  other  develops  and  takes  a  definite  shape.  Only 
then  do  we  recognize  the  fact  which  has  existed  for  all  time. 
Such  recognition  is  different  from  mere  knowledge.  Knowledge 
broadens  into  recognition  when  we  appreciate  not  only  that  a 
thing  is  so,  but  also  why  it  is  so.  Facts  themselves  persist  with- 
out change.  It  is  the  interpretation  of  these  facts  that  changes. 
Ages  ago  the  manifestations  of  nature  known  as  thunder  and 
lightning  were  no  different  from  what  they  are  to-day,  yet  at 
that  time  they  were  looked  upon  as  expressions  of  disapproval 
on  the  part  of  an  angered  Deity. 

Similarly,  in  the  manifestations  of  life,  all  organisms  have 
always  been  the  same;  for  all  time  the  same  diseases  have  ex- 
isted and  the  causes  and  the  symptoms  of  disease  have  remained 
unaltered.  Psychoses,  too,  together  with  their  productive  causes 
and  their  symptoms,  have  always  been  the  same.  Our  recog- 
nition of  the  physical  and  psychic  manifestations  of  life  under 
normal  and  pathological  conditions,  our  appreciation  of  the 
cause  of  vital  activity  and  its  disorders,  and  our  ability  success- 
fully to  combat  these  disorders,  have  not  remained  the  same, 
however,  but  in  the  course  of  time  have  undergone  manifold  and 
marked  changes.  The  mental  effort  of  generations  of  human 
beings  was  required  in  order  that  we  should  be  able  to  under- 
stand that  the  endless  circles  of  life,  the  unceasing  alternations 

19 


20       THE  UNSOUND  MIND  AND  THE  LAW 

of  beginning  and  end,  of  rise  and  fall,  of  health  and  disease, 
were  not  matters  of  chance  nor  due  to  any  extra-mundane,  un- 
controllable power,  but  were  the  results  of  strictly  ordered  laws. 

In  this  consideration  of  the  historical  development  of  the 
teachings  of  mental  disorder,  I  shall  confine  myself  to  the  usual 
boundaries  of  the  three  main  periods — ancient,  mediaeval  and 
modern  times.  This  division  has  the  practical  advantage  of 
keeping  the  history  of  psychoses  undetached  from  the  history  of 
medicine  in  general,  for  the  development  of  the  teachings  of 
pathological  mental  states  has  necessarily  stood  in  reciprocal  re- 
lationship to  that  of  the  other  branches  of  medicine.  Moreover, 
medicine  itself,  in  all  the  phases  of  its  history,  shows  its  de- 
pendence upon  the  intellectual  culture  that  has  existed  at  vari- 
ous times.  The  status  of  the  intellectual  culture  of  ancient  times 
is  characterized  by  its  unsophisticated  consideration  of  nature 
and  its  confounding  of  natural  forces  with  gods  and  demons. 
During  the  middle  ages  all  of  medicine,  including  psychiatry, 
stood  under  the  sway  of  scholastic  philosophy.  It  was  not  until 
the  sixteenth  century  that  medicine  gradually  emerged  from  the 
bane  of  speculative,  deductive  modes  of  thought ;  then  the  adop- 
tion of  inductive  methods  of  investigation  brought  medicine  into 
the  ranks  of  the  exact  natural  sciences.  By  no  means  would 
I  have  it  understood  that  a  knowledge  of  the  psychoses  developed 
concordantly  with  the  remaining  branches  of  medicine.  This 
could  not  have  been  the  case,  if  for  no  other  reason  than  that  the 
mind  from  all  time  had  been  considered  something  apart  from 
the  body,  and  the  disorders  of  its  activity,  therefore,  were  not 
looked  upon  as  disease  in  the  usual  sense  of  this  word.  It  was 
long — far  into  modern  times,  in  fact — before  the  principle  be- 
came generally  recognized  that  the  science  of  the  mind  and  its 
diseases  was  one  of  the  branches  of  the  natural  sciences.  It  is 
from  the  time  of  this  recognition  that  psychiatry  may  be  said 
to  have  begun  to  exert  an  important  influence  upon  forensic 
medicine. 

In  my  historical  reflections,  therefore,  it  is  my  aim  to  show, 
upon  the  one  hand,  how  psychiatry,  under  the  influence  of  the 
varied  intellectual  tendencies  which  characterize  the  three 
chief  periods  of  time  we  have  mentioned,  has  developed  with  the 
other  branches  of  medicine,  and  upon  the  other  hand,  particu- 
larly, how  the  study  of  insanity  reenforced  by  its  amalgamation 


HISTORICAL  RETROSPECT       21 

with  brain  and  nerve  physiology  gradually  became  quite  as  im- 
portant to  jurisprudence  as  had  been  the  science  of  legal  medi- 
cine, whose  existence  long  antedated  that  of  forensic  psychiatry. 
This  historical  introduction  can,  of  course,  lay  no  claim  to  com- 
pleteness. My  purpose  is  essentially  to  mark  the  milestones  that 
guide  us  upon  the  developmental  path  of  the  science  of  the 
psychoses,  so  that  the  physician  and  the  jurist  will  understand 
how  the  fantastic,  theologically  or  philosophically  colored 
notion  of  an  unmaterial  mind,  with  its  non-physical  disorders, 
has  gradually  been  transformed  into  an  actual  recognition  of  the 
psychoses  and  an  understanding  of  the  annulment  or  limitation 
of  responsibility  which  they  may  cause. 

A.    Ancient  Times 

The  statement  is  often  made  that  mental  diseases  were  far 
more  infrequent  in  ancient  times  than  they  are  to-day.  This 
remark  seems  to  find  its  support  in  the  fact  that  only  excep- 
tionally do  the  inscriptions  upon  ancient  obelisks,  tombs,  etc., 
which  recount  all  important  happenings,  mention  the  occurrence 
of  insanity.  This  conclusion,  of  course,  is  not  justifiable,  be- 
cause the  very  inscriptions  which  refer  to  the  existence  of 
psychoses  may  have  been  lost,  and  because  many  psychoses,  par- 
ticularly in  those  times,  remained  unrecognized.  On  the  other 
hand,  while  it  cannot  be  denied  that  the  haste  of  modern  life  and 
the  exhausting  struggle  for  existence  encourage  an  increase  of 
mental  disturbance,  it  is  impossible  for  us  to  furnish  any  sta- 
tistical basis  that  would  permit  us  to  express  in  actual  numbers 
the  amount  of  this  increase. 

I  need  but  recall  that  during  the  first  half  of  the  eighteenth 
century  women  who  were  probably  sufferers  from  mental  dis- 
order were  burned  at  the  stake  as  witches.  Until  well  into  mod- 
ern times,  thousands  of  such  unfortunates  met  with  death  by  fire 
because  they  were  believed  to  be  possessed  of  demons  and  were 
not  considered  insane.  Under  such  conditions  how  can  it  be 
expected  that  the  priests  or  others  who  in  ancient  times  occupied 
themselves  with  the  healing  art  should  have  had  any  clear  notion 
of  mental  disorders? 

Exactly  as  during  the  middle  ages  many  insane  were  believed 
to  be  witches,  so  in  ancient  times  many  persons  who  talked  irra- 


22       THE  UNSOUND  MIND  AND  THE  LAW 

tionally  or  acted  in  a  turbulent  and  disorderly  manner  were  un- 
doubtedly looked  upon  as  intoxicated  or  criminal.  At  any  rate 
we  must  assume  that  transitory  insanity  and  the  early  stages  of 
chronic  mental  disorders,  in  which  characteristic  symptoms  are 
not  easily  recognizable,  were  not  considered  as  psychoses  and, 
therefore,  were  not  included  among  them.  According  to  Haeser, 
the  earliest  accurate  accounts  of  insanity  are  to  be  found  in 
Hippocrates  (460  B.  C).  Just  as  the  Greeks  towered  above  all 
other  peoples  of  antiquity  in  their  intellectual  culture,  so  did 
their  medical  teachings,  although  not  upon  a  level  with  their 
achievements  in  art,  philosophy  and  poetry,  far  surpass  the 
plane  occupied  by  Egyptian,  Judaic  and  Oriental  medicine.  In 
the  eyes  of  the  latter,  health  represented  more  or  less  a  gift  of 
propitious  powers,  while  its  loss — disease — was  believed  to  be  the 
influence  of  demonic  forces.  How  differently  do  we  find  this 
question  treated  by  Hippocrates!  He  considers  mental  dis- 
orders to  be  dependent  essentially  upon  bodily  causes,  and 
associates  them  more  especially  with  diseases  of  the  brain,  al- 
though he  had  but  scant  knowledge  of  the  build  and  function  of 
this  organ.  Thus  he  believed  it  to  be  the  function  of  the  brain 
to  gather  the  excess  of  mucus  which,  if  not  so  gathered,  would 
produce  catarrh,  and  to  secrete  the  seminal  fluid,  which  then 
was  conducted  through  the  spinal  cord  to  the  testicles.  The 
astonishing  lack  of  accurate  knowledge  among  the  Greeks  of  the 
classic  period  is  undoubtedly  closely  related  to  the  aversion  they 
entertained  toward  dismembering  the  dead  human  body.  All 
the  knowledge  they  possessed  concerning  the  interior  construc- 
tion of  the  human  organism  was  derived  from  the  wounds  re- 
ceived or  inflicted  in  battle.  This  also  explains  why,  in  those 
martial  times,  the  art  of  healing  was  almost  exclusively  a 
surgical  one.  Notwithstanding  all  this,  Hippocrates  had  been 
able  to  formulate  the  opinion  that  the  anatomically  so  much 
neglected  brain  was  the  central  organ  for  thought,  sensation 
and  motion. 

It  is  true,  however,  that  the  mental  disturbances  which  often 
accompany  bodily  diseases  were  sharply  differentiated  from  the 
psychoses  as  such.  The  Hippocratists  knew  but  two  funda- 
mental forms  of  mental  disease — melancholia  and  mania — but 
these  terms  by  no  means  carried  with  them  that  sharp  differen- 
tiation which  they  do  to-day.     The  term  melancholia  designated 


HISTORICAL  RETROSPECT       23 

all  psychic  diseases  that  were  presumably  caused  by  an  excess  of 
bile.  The  term  mania,  on  the  other  hand,  referred  to  insanity 
in  general.  Special  consideration  was  bestowed  upon  epilepsy 
and  upon  the  question  whether  this  affection  was  dependent 
upon  supernatural  causes.  Hippocrates  expressed  himself  decid- 
edly in  favor  of  its  somatic  origin  and  against  the  sympathetic 
and  superstitious  means  of  treatment  that  then  prevailed.  His 
remarks  upon  the  influence  of  heredity,  his  description  of  the 
epileptic  aura  and  of  the  attack  itself,  are  in  every  way  appro- 
priate. Hence  it  may  well  be  said  that,  as  compared  with  the 
prevailing  views  upon  medicine  and  the  natural  sciences,  Hippo- 
cratic  psychiatry  had  already  attained  a  level  of  astonishing  pre- 
eminence. No  matter  what  may  have  been  its  faults  and  omis- 
sions, it  had  thoroughly  grasped  the  fundamental  truth,  ap- 
preciation of  which  was  later  again  lost,  that  psychoses  are  dis- 
eases of  the  brain. 

Let  us  now  pass  to  the  question  of  the  study  of  psychiatry 
among  the  Romans.  This  should  bespeak  our  special  interest  as 
it  is  there  that  a  comprehension  of  the  intimate  relation  between 
jurisprudence  and  medicine  was  for  the  first  time  thoroughly 
appreciated.  Whether  the  old  Roman  law  recognized  psychiatry 
as  an  accredited  science  and  accepted  its  decision  in  cases  of 
doubtful  mental  disorder  is  uncertain.  On  the  other  hand,  we 
do  know  that  the  legal  relations  of  the  insane  were  better  reg- 
ulated among  the  Romans  than  among  the  other  people  of 
ancient  times,  and  that  they  reveal  a  clearness  of  understanding 
for  the  notion  of  responsibility  that  must  be  considered  re- 
markable. It  is  true  this  commendable  condition  of  affairs  was 
due  less  to  the  Romans  themselves  than  to  their  instructors,  the 
Greeks.  Real  Roman  medicine  existed  to  just  as  slight  a  degree 
as  did  real  Roman  philosophy  or  art.  Whatever  of  medicine 
was  found  among  the  Romans  was  due,  just  as  was  the  rest  of 
their  mental  culture,  to  Hellenic  influence.  The  two  most  prom- 
inent physicians  of  that  period,  Celsus  (Aurelius  Cornelius,  first 
half  of  the  first  century)  and  Galen  (160  A.  D.)  confined  them- 
selves in  the  main  to  the  Hippocratic  teachings,  elaborating  cer- 
tain points,  yet  forcing  certain  others  back  to  a  lower  level.  This 
we  can  understand  when  we  recall  that,  although  the  Romans 
subordinated  themselves  to  the  higher  mental  culture  of  the 


24   THE  UNSOUND  MIND  AND  THE  LAW 

Greeks,  they  still  remained  conservative  in  their  fundamental 
views. 

Almost  to  the  end  of  the  Republic,  the  Romans,  who  were  the 
most  superstitious  of  all  the  ancients,  had  recourse  in  all  their 
public  and  private  afflictions  to  the  Sibylline  books,  and  to  sacri- 
ficial offerings  to  the  numerous  gods,  who  to  their  minds  con- 
stituted all  amicable  and  inimical  forces  of  nature.  In  the 
mythology  of  the  Greeks,  as  we  know,  the  gods  and  the  god- 
desses with  whom  they  peopled  their  transcendental  world  also 
played  an  important  part.  Hippocrates  and  his  disciples,  how- 
ever, attributed  to  this  world  of  deities  but  a  passive  influence 
upon  disease.  Galen  on  the  other  hand  was  governed  by  the 
idea  that  the  course  of  all  vital  manifestations  was  regulated  by 
the  power,  wisdom  and  beneficence  of  the  Maker  of  the  universe. 
Man  himself  was  but  a  passive  instrument.  Hence,  the  task  of 
medicine  could  but  be  that  of  accurately  describing  the  different 
diseases  and  the  alteration  which  they  produced. 

In  this  direction  Galenic  medicine  attained  extraordinary  dex- 
terity. But,  as  it  devoted  no  attention  to  the  etiology  of  dis- 
ease, or  covered  it  with  a  veil  of  mysticism  that  was  even  worse 
than  total  disregard,  the  Galenic  influence  upon  the  development 
of  Roman  medicine  represented  no  more  than  a  revival  of  the 
doctrines  already  expressed  by  Hippocrates,  namely,  that  ob- 
servation and  the  experiment  constitute  the  sole  permissible 
means  of  investigation  in  medicine  and  the  natural  sciences. 
The  later  Greeks  did  not  apply  this  perfectly  correct  principle 
to  the  study  of  the  etiology  of  disease  as  Hippocrates  had  done. 
It  is  for  this  reason  that  we  should  not  be  astonished  when  we 
find  Galenic  medicine  in  general,  and  Galenic  psychiatry  in  par- 
ticular, representing  a  retrogression  rather  than  an  advance. 
Galen  placed  an  enigmatical  "pneuma"  first  among  the  factors 
which  produced  vital  activity.  It  cannot  be  determined  from 
his  writings,  according  to  Haeser,  that  he  ascribed  the  origin  of 
mental  disease  to  bodily  causes  or  assumed  any  connection  to 
exist  between  them  and  diseases  of  the  brain.  His  conception  of 
the  structure  and  function  of  the  central  nervous  system  was  ex- 
ceedingly primitive.  Galen  classified  the  nerves  according  to 
their  consistency,  into  hard,  soft  or  medium  ones.  The  sensory 
nerves  he  placed  in  the  first  class,  those  of  the  spinal  cord,  which 
he  believed  to  be  entirely  motor,  were  of  the  second  class,  and 


HISTORICAL  RETROSPECT       25 

the  third  class  was  made  up  of  the  nerves  of  the  medulla  oblon- 
gata, with  both  motor  and  sensory  functions.  That  certain 
cranial  nerves  were  motor  in  character,  Galen  explained  by  say- 
ing that  they  became  more  and  more  consistent  during  their 
course,  and  thus  were  transformed  from  sensory  into  motor 
nerves;  the  fact  that  all  nerves  did  not  originate  in  the  brain, 
but  that  some  arose  from  the  spinal  cord,  according  to  this  same 
authority,  was  due  to  the  circumstance  that  if  they  all  started 
from  the  brain  their  extreme  length  would  have  exposed  them 
to  the  danger  of  being  easily  torn. 

' '  Pneuma, ' '  the  life-giving  force,  took  its  origin  in  the  lateral 
ventricles  of  the  brain  from  the  blood  of  the  carotids  and  then 
through  a  passageway  (the  aquasductus  Sylvii)  entered  the 
fourth  ventricle,  whence  according  to  need  it  was  distributed  to 
the  various  parts  of  the  body.  In  this  procedure  the  vermis  of 
the  cerebellum  acted  as  a  sort  of  a  "  bolt. ' '  The  ganglia  served 
as  an  apparatus  by  means  of  which  the  nerves  were  reenforced. 

The  diseases  of  the  brain  dependent  upon  angemia  were  care- 
fully differentiated  from  those  due  to  hypersemia.  The  former 
caused  convulsions  and  paralysis,  the  latter  apoplexy — not  in 
consequence  of  extravasation  of  the  blood,  but  as  a  result  of  an 
accumulation  of  mucus.  The  law  of  cerebral  decussation  in 
paralyses  was  well  known  to  Galen.  Thus  we  find  his  system 
containing  an  astonishing  admixture  of  truth  and  fiction, 
especially  so  when  he  attempts  to  explain  the  results  of  his  in- 
vestigations. He  clearly  recognized  the  more  distinct  psychoses, 
but  had  no  notion  of  their  cause.  Fortunately  the  Roman  jurists 
had  a  sufficiently  clear  understanding  of  insanity  to  enable  them 
to  regard  the  mere  fact  of  its  existence  as  a  warrant  for  the 
assumption  that  free  determination  and  responsibility  were  an- 
nulled or  restricted.  Whether  the  existence  of  insanity  had  to 
be  determined  by  expert  physicians,  or  whether  the  magistrates 
had  to  decide  this  question  from  their  own  observation,  is  not 
known.  But  it  is  much  to  their  credit  that  they  considered  the 
existence  of  insanity  a  fact  by  itself  and  that  from  the  view- 
point of  the  law  they  believed  it  to  be  immaterial  whether  this 
unfortunate  state  was  brought  about  by  natural  causes  or  by 
the  influence  of  the  gods  or  demons.  The  well-known  states  of 
depression  and  exaltation  as  they  manifest  themselves  in  melan- 
cholia and  mania  were  amplified  by  Celsus  through  the  addition 


26       THE  UNSOUND  MIND  AND  THE  LAW 

of  those  states  that  are  characterized  by  hallucinations  and  fixed 
ideas.  Not  one  of  the  ancient  writers  makes  any  mention  of 
isolation  of  the  insane.  The  old  Roman  provision  that  the  in- 
sane must  be  guarded  by  their  relatives  is  significant  merely 
because  it  was  a  police  ordinance.  The  manner  in  which  the 
Roman  law  regulated  the  legal  relations  of  the  insane  in  civil 
questions  is  shown  by  its  provision  for  the  establishment  of  a 
curatelle.  Historically  such  a  guardianship  is  first  encountered 
in  the  Roman  law  on  account  of  improvidence.  This  curatelle 
(interdictio),  based  upon  the  time-honored  law  of  custom,  or 
common  law,  was  originally  applied  in  cases  of  the  dissipation 
of  a  patrimony  inherited  through  lawful  succession  and  not 
through  testamentary  bequest.  Later  this  limitation  of  the 
curatelle  to  improvidence  can  no  longer  be  found  in  the  Roman 
law.  By  means  of  the  magisterial  degree  of  interdiction,  the 
spendthrift  was  placed  upon  a  par  with  an  immature  minor. 
There  was  assigned  to  him  a  guardian  (curator)  whose  sanction 
for  the  transaction  of  business  was  governed  by  a  variety  of 
considerations.  The  spendthrift  was  entirely  incompetent  to 
make  a  will  or  testament.  No  formal  standard  for  the  establish- 
ment of  a  curatelle  solely  on  account  of  insanity  can  be  found  in 
the  Roman  law.  But  transactions  carried  out  in  a  state  of  in- 
sanity were  ineffective,  the  insane  person  being  as  incompetent 
as  a  child  under  seven  years  of  age.  On  the  other  hand,  he  who 
was  merely  feeble-minded  but  not  "insane"  continued  to  main- 
tain the  same  privileges  as  a  person  who  was  mentally  healthy. 
In  cases  of  mental  disorder  of  long  duration,  a  guardian  was 
appointed  to  act  in  place  of  the  patient,  but,  in  case  of  the  occur- 
rence of  so-called  lucid  intervals,  the  patient  at  once  became 
legally  competent  to  act  for  himself  without  any  formal  annul- 
ment of  the  existing  guardianship.  How  unsatisfactory  such  a 
state  of  affairs  must  have  been  from  a  business  point  of  view 
may  easily  be  conceived. 

B.  Middle  Ages 

If  we  allow  the  intellectual  trends  that  directed  culture  in 
the  middle  ages  to  pass  before  us  in  review,  we  will  find  that 
probably  no  one  of  them  had  so  great  and  lasting  an  influence 
upon  medicine  and  natural  thought  as  did  scholastic  philosophy. 


HISTORICAL  RETROSPECT       27 

Generally  speaking,  philosophy  is  the  science  of  the  ultimate 
causes  of  all  things.  It  endeavors  to  explain  the  entire  realm 
of  manifestations,  their  development  and  their  purpose,  their 
beginning  and  their  end.  The  attempt  to  solve  these  problems 
by  the  aid  of  pure  reason  usually  fails,  because  inevitably  pure 
reason  very  soon  reaches  the  limits  of  the  recognizable.  Then  it 
must  resort  to  hypotheses  which  can  never  be  looked  upon  as 
proof,  for  they,  being  suppositions,  must  first  be  proved.  This 
dilemma  explains  why  transcendental  notions  have  from  the  be- 
ginning of  time  played  so  great  a  part  in  philosophy.  But  in 
ancient  times  philosophy  was  theologically  tinged,  inasmuch  as 
it  endeavored  more  or  less  to  explain  the  unrecognizable  by  the 
assumption  of  the  existence  of  intangible  powers,  which  were 
usually  conceived  as  divinities.  Even  a  mental  giant  so  unprej- 
udiced and  practical  as  Aristotle  could  not  emancipate  himself 
from  the  belief  in  the  existence  of  extramundane  powers  and 
supernatural  forces. 

The  scholasticism  which  in  the  middle  ages  dominated  all 
mental  life,  and,  therefore,  also  all  medical  thought,  differs  ma- 
terially, however,  from  the  classic  philosophy  of  the  ancients. 
The  characteristic  distinction  seems  to  me  to  be  that  the  latter 
was  a  theologically  colored  philosophy,  while  the  former  was  a 
philosophically  colored  theology.  The  ancient  philosophers  ac- 
cepted transcendental  notions  as  a  necessary  evil,  as  an  indis- 
pensable aid  in  the  interpretation  of  the  universe.  To  them  the 
important  factor  was  the  insight  that  they  acquired  through 
pure  reason.  The  reasoning  of  the  scholastics  was  just  the  re- 
verse. To  them  theology  represented  the  important  factor, 
while  philosophy  was  merely  the  means  to  an  end.  The  prom- 
inent trait  of  scholasticism  is  the  endeavor  to  demonstrate  the 
omnipotence,  the  wisdom  and  the  bounty  of  the  Creator  from 
his  works — that  is,  from  nature.  The  philosophy  of  pure  rea- 
son did  not  accept  the  existence  of  this  Creator  as  an  apriori 
fact,  but  it  was  accepted  as  a  hypothesis  merely  for  the  purpose 
of  explaining  the  primary  origin  of  all  things.  In  scholasticism, 
on  the  other  hand,  the  Mosaic  report  of  the  Creator  and  all  other 
portions  of  the  Bible  referring  to  the  nature  of  man,  and  also 
the  biblical  conception  of  demonic  possession  as  an  explanation 
of  insanity,  were  unreservedly  accepted  as  a  revelation  of  truths 
which  required  no  corroboration  and  to  which  philosophy,  medi- 


28       THE  UNSOUND  MIND  AND  THE  LAW 

cine  and  nature  study  must  be  made  subservient.  Hence,  the 
purpose  of  science  could  not  be  to  demonstrate  facts  objectively, 
but  merely  so  to  aid  theology's  interpretation  of  the  facts  of 
nature,  the  vital  manifestations  of  the  organism's  disorders  of 
health,  etc.,  that  it  would  accord  with  the  teachings  recorded  in 
the  Bible. 

For  philosophy,  therefore,  it  was  theology,  and  for  scholas- 
ticism it  was  philosophy,  that  represented  the  means  to  an  end. 
Philosophy  started  from  pure  reason  and  made  use  of  the  con- 
ception of  an  extramundane  power  merely  as  an  unavoidable  aid 
in  explaining  the  unrecognizable.  Scholasticism  on  the  other 
hand  started  from  the  Creator  of  all  things  as  a  fact  requiring 
no  proof,  and  made  use  of  science  merely  as  a  support  for  its 
sophistical  dialectic  in  order  that  it  might  interpret  the  realm 
of  natural  manifestations.  These  reflections  enable  us  to  under- 
stand how  scholasticism  exerted  its  restraining  influence  not 
only  upon  the  study  of  medicine  in  general,  but  upon  that  of 
psychiatry  in  particular.  To  this  scholastic  influence  more  than 
to  anything  else  must  we  ascribe  the  fact  that  medicine  in  gen- 
eral, during  a  period  of  more  than  a  thousand  years,  had  shown 
practically  no  evidence  of  any  progressive  growth,  and  that 
psychiatry  during  this  time  not  only  showed  no  advance,  but 
may  even  be  said  to  have  retrogressed.  Strange  as  it  may  ap- 
pear, it  is  a  fact  that  at  the  end  of  the  middle  ages,  in  the  six- 
teenth century,  medicine  occupied  about  the  same  plane  as  it  did 
at  the  beginning  of  this  period,  or  perhaps  even  a  lower  one ;  so 
that  modern  medicine  may  be  said  to  start  where  that  of  the 
ancients  ceased. 

Psychiatry  had  a  more  difficult  road  to  travel  than  even  the 
other  branches  of  medicine,  for  after  the  inductive  methods  of 
observation  and  experimentation  had  taken  root  in  their  soil, 
psychiatry  was  still  looked  upon  as  occupying  a  special  position 
— as  being  an  intellectual  science. 

Even  as  used  to-day  the  expression  "mental  disease"  is  mis- 
leading, inasmuch  as  it  conveys  the  impression  of  a  disease  of 
the  mind  as  opposed  to  a  disease  of  the  body.  As  a  matter  of 
fact,  no  such  opposition  exists.  Mental  disease  is  bodily  disease, 
and  differs  from  other  forms  of  such  affliction  merely  by  reason 
of  the  fact  that  it  has  its  seat  in  the  brain.  Not  every  brain 
disease  is  mental  disease.     But  every  mental  disease  is  brain  dis- 


HISTORICAL  RETROSPECT       29 

ease,  even  when  no  anatomical  lesion  of  the  brain  is  discoverable. 
This  fact,  which  Hippocrates  had  already  suspected  and  voiced, 
has  not  acquired  general  endorsement  even  in  modern  times,  to 
say  nothing  of  the  middle  ages.  During  the  middle  ages,  in 
fact,  this  most  important  truth  was  throttled  and  buried  under 
the  superstitious  belief  in  demonic  possession.  Mediaeval  psy- 
chiatry, therefore,  does  not  even  exemplify  a  transition  from 
ancient  to  modern  teachings,  but  represents  a  period  of  decline, 
which  could  be  checked  only  after  innumerable  errors  had  been 
overcome. 

The  deplorable  state  of  psychiatry  in  the  middle  ages  is 
clearly  shown  by  all  works  upon  the  history  of  civilization  that 
treat  of  this  period.  It  is  true  we  find  mediaeval  reports  of 
mental  disorders,  even  of  such  as  occurred  in  epidemic  distribu- 
tion, such  as  dance  madness,  lykanthropy  or  the  belief  in  the 
transformation  of  human  beings  into  ' '  man  wolves, ' '  etc. ;  but 
not  a  trace  of  any  scientific  psychiatric  work  can  be  found  to 
have  been  done  during  these  benighted  years.  As  late  as  the 
seventeenth  century  the  only  treatment  for  what  we  now  call 
insanity  was  exorcism  or  imprisonment.  Here  and  there,  as  in 
Hamburg,  Frankfort  on  the  Main,  Wiirzburg,  and  a  few  other 
towns,  the  quiet  insane  were  confined  in  institutions  specially 
provided  for  the  purpose,  and  in  these  they  received  more  or 
less  humane  treatment.  We  must  not  lose  sight  of  the  fact, 
however,  that  the  most  extraordinary  confusion  regarding  the 
diagnosis  of  insanity  existed  at  that  time.  Insane  patients  who 
spoke  or  acted  sacrilegiously  were  supposed  to  be  possessed  of 
the  devil ;  those  who  suffered  from  sense  deceptions  of  a  religious 
nature,  who  had  visions  of  heavenly  apparitions,  were  often 
honored  as  saints.  Many  persons  who,  according  to  modern 
ideas,  were  mentally  healthy,  were  declared  insane  because  they 
expressed  ideas  which  could  not  be  understood  by  their  associ- 
ates; others  who  were  actually  insane,  and  in  that  state  com- 
mitted murder  or  other  serious  crime,  were  delivered  to  the 
sanguinary  executioner  by  the  pitiless  law  of  those  times.  No- 
where was  the  thought  expressed  that  the  question  of  freedom  of 
the  will  and  responsibility  in  criminals,  even  when  they  ap- 
peared to  be  abnormal,  was  one  that  should  be  submitted  to 
medical  experts.  The  people  of  the  middle  ages,  all  in  all,  were 
neither  more  brutal  nor  more  unjust  than  the  people  of  to-day, 


30   THE  UNSOUND  MIND  AND  THE  LAW 

but  they  were  boundlessly  ignorant  and  governed  by  crass  preju- 
dice and  superstition. 

C.  Modern  Times 

At  the  commencement  of  modern  times  we  find  the  funda- 
mental views  in  medicine  according  almost  entirely  with  those 
of  Hippocrates.  Medical  science  of  the  sixteenth  century  made 
its  start  at  the  point  where  it  had  been  left  by  the  ancients. 
The  entire  middle  ages  seem  to  have  passed  by  all  scientific  in- 
vestigation of  nature 's  manifestations  without  leaving  any  mark 
of  progress;  on  the  contrary,  there  was  a  retrogression  during 
this  period.  The  soil  of  the  middle  ages  had  been  prepared  for 
development  by  Greek  medicine.  Had  this  era  made  good  use 
of  its  heritage,  the  science  of  medicine  could  not  have  failed  to 
advance.  The  task  that  fell  to  the  middle  ages  was  a  far  easier 
one  than  that  with  which  the  classic  period  of  antiquity  had  to 
deal,  for  it  had  but  to  continue  the  structure  upon  the  ground 
work  that  had  already  been  prepared.  This,  as  I  have  shown, 
had  not  been  accomplished,  and  the  reasons  have  already  been 
given  why  a  stagnation  in  the  studies  of  medicine  and  the  nat- 
ural sciences  should  have  lasted  until  about  the  time  of  the  in- 
vention of  the  art  of  printing,  the  discovery  of  America,  and  the 
Reformation.  The  power  of  the  scholastic  spirit  had  first  to  be 
broken,  and  this,  because  of  the  scientific  garb  with  which  it  had 
succeeded  in  enveloping  itself,  was  necessarily  a  slow  procedure. 

Individuals  like  Giordano  Bruno,  Roger  Bacon,  etc.,  pioneers 
of  free  investigation,  men  who  were  willing  to  sacrifice  liberty 
and  life  to  their  convictions,  found  few  followers.  The  six- 
teenth century  constitutes  an  epoch  in  history  the  significance 
of  which  can  be  compared  to  no  other.  In  all  fields  of  life  an 
unparalleled  reaction  was  taking  place.  This  change,  whose 
beginnings  in  many  instances  reached  back  to  a  far  earlier 
period,  often  enough  showed  its  effect  only  at  a  much  later  time. 
Many  of  the  new  inventions  and  discoveries  (microscope,  tele- 
scope, chemistry,  etc.)  proved  of  inestimable  advantage  to  the 
natural  sciences.  Medicine  derived  great  advantage  from  the 
studies  of  the  humanists,  inasmuch  as  a  knowledge  of  the  heal- 
ing art  as  it  had  been  developed  in  the  classic  period  had  been 
transmitted    only   by   means    of   the    distorted    and   mutilated 


HISTORICAL  RETROSPECT  31 

scholastic  editions  of  the  Latin  translations  of  the  works  of  Hip- 
pocrates, Aristotle  and  others,  and  a  reconstruction  of  the  orig- 
inal text  often  cast  an  entirely  different  light  upon  the  medical 
views  of  the  classicists.  Among  other  facts  it  was  thus  estab- 
lished that  Hippocrates  had  attributed  the  origin  of  the 
psychoses  to  natural  causes  and  also  had  declared  them  to  be  dis- 
eases of  the  brain.  Many  physicians  of  the  sixteenth  century 
soon  were  found  energetically  opposing  the  prevailing  methods 
of  treatment  by  means  of  exorcism  of  evil  spirits  and  other  meas- 
ures of  restraint.  Together  with  these  and  many  other  gratify- 
ing effects  of  progressive  enlightenment  in  the  field  of  nature 
study  and  anthropology,  we  must  note  the  gradual  disappear- 
ance of  the  ridiculous  views  that  had  been  held  in  regard  to  the 
relationship  of  body  and  mind.  How  slowly  this  progress  was 
achieved,  however,  is  exemplified  by  Paracelsus  (Philippus 
Aureolus,  1493-1541),  who  may  well  be  looked  upon  as  one  of 
the  most  enlightened  men  of  the  first  half  of  the  sixteenth  cen- 
tury and  one  of  the  most  capable  physicians  of  those  times.  As 
in  all  medicine,  so  in  psychiatry  Paracelsus  represents  the  trans- 
ition from  the  middle  ages  to  the  modern  era.  The  nature  of  his 
psychiatric  views,  as  Kornfeld  states,  is  exemplified  upon  the 
one  hand  by  his  doctrine  that  every  disease  represents  a  living 
thing  that  bears  the  same  relation  to  the  body,  for  instance,  as  a 
parasite  does  to  a  tumor  growth,  and  runs  a  different  course  in 
each  individual  according  to  age,  sex  and  peculiarity.  Upon  the 
other  hand,  Paracelsus  differentiated  between  the  visible  and 
tangible  body,  and  the  invisible,  intangible,  celestial  or  astral 
body,  which  reigned  as  an  active  force  and  vital  spirit  in  the 
mundane  body.  Just  as  the  natural  instincts  had  their  base  in 
the  mundane  body,  so  all  the  arts  and  all  natural  intelligence 
had  their  base  in  the  astral  body. 

That  Paracelsus  was  devoted  to  astrology  is  shown  by  his 
views  concerning  the  influence  supposedly  exerted  by  the  heav- 
enly bodies  and  the  various  constellations  upon  physical  as  well 
as  upon  mental  disease.  Man  appeared  to  him  as  a  "little 
world"  (microcosm)  in  which  the  "large  world"  (macrocosm, 
universum)  embodied  itself.  At  the  time  of  the  full  moon  and 
of  the  new  moon,  insanity  increased  because  the  brain  was  the 
microcosmic  moon.  The  prime  beginnings  of  all  diseases  lay  in 
salt,  sulphur  and  mercury;  through  heat,  mercury  became  sub- 


32       THE  UNSOUND  MIND  AND  THE  LAW 

Unrated,  precipitated  and  distilled.  Sublimation  caused  mania; 
precipitation  caused  gout,  distillation  caused  paralysis  and  mel- 
ancholia. Against  mania,  Paracelsus  recommended  the  use  of 
the  actual  cautery,  the  application  of  which  was  to  be  governed 
by  the  direction  of  the  wind.  Moreover,  he  specially  mentioned 
venesection  as  a  means  of  treatment,  and  the  influence  of  colors 
upon  the  emotions  was  well  known  to  him  and  was  therapeutic- 
ally utilized.  Paracelsus  is  the  typical  exemplification  of  that 
fermenting  transitional  period  in  which  we  find  new  ideas  in 
constant  contest  endeavoring  to  wrest  the  wand  of  supremacy 
from  one  another.  If  it  was  possible  for  the  one  man  whose 
knowledge  and  mentality  towered  above  that  of  the  majority  of 
physicians  of  that  period  and  also  above  that  of  his  contem- 
poraries in  general,  to  evolve  such  a  peculiar  conglomeration  of 
old  and  new  ideas,  what  could  we  expect  of  other  investigators 
and  thinkers? 

Extraordinary  and  absurd  as  the  views  of  Paracelsus  may  ap- 
pear to  us,  there  can  be  no  doubt  that  he  had  surmised  many  a 
truth,  whose  correctness,  however,  was  acknowledged  only  at  a 
much  later  period.  The  study  of  his  writings  is  of  peculiar  in- 
terest because  they  reveal  the  beginnings  of  not  a  few  ideas 
which  later,  as  newly  discovered  facts,  acquired  a  certain  signifi- 
cance. Thus  we  find  venesection  being  employed  to-day  for  the 
relief  of  hyperasmia  of  the  brain ;  the  spiritists  have  again  disin- 
terred the  "astral  body";  modern  helio-therapy  ascribes  an  im- 
portant role  to  the  influence  of  colors  upon  animal  states;  the 
relationship  that  the  phases  of  the  moon  are  supposed  to  bear 
to  the  manifestations  of  somnambulism  has  been  rediscovered 
various  times  since  Paracelsus  first  affirmed  its  existence. 

Let  us  now  examine  more  closely  the  influence  exerted  by 
modern  times  upon  the  eradication  of  the  belief  in  astrology, 
alchemy  and  witchcraft,  as  well  as  of  superstition  in  general. 
We  find  that  Wyer  in  particular  acquired  lasting  renown 
through  writings  directed  against  Sprenger,  the  notorious  Do- 
minican monk.  In  these  he  attacked  the  folly  of  witch  prosecu- 
tion and  witch  destruction;  but  Wyer  alone  was  by  no  means 
able  to  eradicate  the  witchcraft  delusions.  This  obsession  con- 
tinued to  exist  not  only  among  the  lower  classes,  but  also  among 
the  educated,  so  that  even  as  late  as  the  year  1749  we  find  the 
medical  faculty  of  the  University  of  Wiirzburg  endorsing  the 


HISTORICAL  RETROSPECT  33 

death  sentence  pronounced  upon  a  witch  by  the  theological 
faculty  of  that  university. 

Only  in  view  of  this  firmly  rooted  superstition,  one  which 
controlled  people  of  all  classes,  can  we  comprehend  how  it  was 
that  witchcraft  prosecutions  could  be  continued  even  into  mod- 
ern times,  not  only  in  Catholic  communities,  but  also  in  Protes- 
tant countries,  and  particularly  in  the  State  of  Massachusetts 
(Salem).  Wyer's  polemics,  written  in  the  Latin  language,  must 
have  been  known  in  America  as  well  as  Europe,  but  his  ardent 
words  had  little  effect,  because  the  time  had  not  yet  come  for  a 
differentiation  between  hysteria  and  witchcraft.  To  have 
proper  regard  for  historical  facts,  we  must  state  that  the  voices 
raised  against  witchcraft  delusions  were  not  alone  those  of  phy- 
sicians, but  in  great  part  those  of  theologians,  and  the  opposition 
of  the  latter  could  not  fail  of  effect.  Blind  belief  in  authority 
certainly  received  a  severe  blow.  Independent  minds  refused 
longer  to  subject  themselves  thoughtlessly  to  theological  and 
philosophical  dogmas,  and  the  investigations  of  the  natural 
sciences  were  soon  directed  into  those  new  paths  that  led  to  the 
inventions  and  discoveries  which  in  the  sixteenth  century  so 
rapidly  followed  one  upon  the  other.  The  world  in  general,  and 
man 's  place  in  nature  in  particular,  soon  appeared  in  an  entirely 
new  light.  The  printing  press  kept  aglow  the  fire  that  glim- 
mered under  the  ashes.  All  those  influences  could  not  help  but 
leave  their  impress  upon  the  further  development  of  medicine, 
and  particularly  of  psychiatry.  More  especially  was  this  prog- 
ress aided  by  the  thorough  reform  inaugurated  in  the  study  of 
anatomy  and  physiology  by  Vesalius  (1514-1564).  Naturally 
his  anatomico-physiological  accomplishments  must  not  be  meas- 
ured by  modern  standards.  Inasmuch  as  he  did  not  have  at  his 
disposal  any  of  the  accessories  of  modern  medicine,  it  is  not  sur- 
prising that  his  conception  of  the  structure  and  functions  of  the 
brain  and  nervous  system  should  have  been  but  an  inadequate 
one.  Whether  Vesalius  looked  upon  the  brain  as  the  seat  of  the 
soul,  and  upon  psychoses  as  brain  diseases,  is  uncertain.  On  the 
other  hand,  we  are  sure  that  Descartes  (1590-1650)  believed  the 
seat  of  the  soul  to  be  the  glandula  pinealis.  Notwithstanding 
this  and  other  errors,  a  decided  step  in  the  right  direction  had 
been  taken.  The  period  of  inductive  investigation  inaugurated 
by  Francis  Bacon  (1561-1626)  gradually  bore  fruit.     Physicians 


34       THE  UNSOUND  MIND  AND  THE  LAW 

and  their  allies,  botanists,  zoologists,  physicists,  chemists,  etc., 
emancipated  themselves  more  and  more  from  the  mystic  motions 
which,  under  the  sway  of  speculative  deductions  alone,  had 
obscured  all  clear  comprehension  of  the  actual  manifestations  of 
nature.  By  confining  themselves  to  observation  and  the  experi- 
ment, and  by  recognizing  that  sensory  perception  constitutes  the 
sole  reliable  source  for  acquiring  a  correct  understanding  of 
these  manifestations  of  nature,  they  recognized  more  and  more 
how  thoroughly  the  actual  state  of  affairs  was  at  variance  with 
their  previous  conceptions. 

The  history  of  psychiatry  in  particular,  however,  demon- 
strates, just  as  our  experience  in  other  fields  of  science  has  again 
and  again  shown,  that  it  is  far  easier  to  assimilate  a  certain 
branch  of  knowledge  step  by  step  without  any  prior  acquaint- 
ance than  it  is  to  begin  such  a  study  on  a  basis  of  erroneous 
notions.  In  the  one  instance  we  commence  by  laying  the  foun- 
dation for  our  subsequent  learning;  in  the  other,  however,  the 
structure  already  erected  must  be  demolished  before  any  build- 
ing can  be  done.  Psychiatry,  though  so  highly  developed  in 
ancient  times,  declined  more  during  the  middle  ages  than  any 
other  branch  of  medicine.  Its  very  foundation  had  been  shaken 
by  the  philosophy  of  scholasticism.  The  entire  study  of  the  soul 
or  mind  was  enshrouded  in  a  dense  fog  of  preconceived  opinions. 
The  soul  was  said  to  be  of  divine  origin,  and  to  have  existed  for 
all  time.  During  procreation  it  was  supposed,  by  special  act  of 
providence,  to  amalgamate  with  the  corporeal  germ.  Neverthe- 
less, the  soul  was  supposed  to  be  and  remain  something  entirely 
uncorporeal  and  to  be  able  to  exist  independently  of  the  body 
itself.  To  overcome  these  deep-rooted  fallacies  was  by  no  means 
easy,  and  hence  we  cannot  be  astonished  if  even  the  most  dis- 
cerning minds  of  that  period,  men  who  pursued  their  anatomical 
and  physiological  studies  in  the  spirit  of  Vesalius  and  who  there- 
fore gave  close  attention  to  the  investigation  of  the  brain  and 
the  mind,  should  have  confounded  truth  and  error  as  they  did. 
It  is  quite  impossible  to  enter  upon  details  here ;  I  can  but  men- 
tion the  chief  representatives  of  the  new  investigational  trend — 
Glisson,  Willis,  Cullen,  Haller,  Stahl,  Sydenham,  Brown. 

The  actual  founder  of  the  modern  science  of  anatomy  and 
physiology  of  the  central  nervous  system,  and  hence  of  modern 
psychiatry,  is  Reii,  whose  special  work  has  served  as  a  basis  for 


HISTOKICAL  RETROSPECT       35 

all  subsequent  investigations  and  particularly  for  those  of 
Bichat,  Bell  and  Johannes  Mueller. 

Before  proceeding  to  a  consideration  of  the  period  immedi- 
ately prior  to  that  of  modern  medicine  I  should  like  to  call  at- 
tention to  the  fact  that  forensic  medicine,  and  with  it,  of  course, 
forensic  psychiatry,  became  an  integral  part  of  jurisprudence 
only  after  1532,  when  the  Emperor,  Charles  V,  persuaded  the 
Diet  of  Ratisbon  to  adopt  a  universal  code  of  penal  juris- 
prudence in  which  the  civil  magistrate  was  required  in  all  cases 
of  doubt  or  difficulty  to  obtain  the  evidence  of  medical  men.  It 
became  the  duty  of  the  medical  officials  to  aid  the  legal  author- 
ities in  the  investigation  of  all  facts  relating  to  personal  injury, 
infanticide,  poisoning,  deaths  by  violence,  etc.,  and  to  assume  the 
care  of  insane  persons,  as  well  as  to  unmask  simulation. 

Kornfeld  corroborates  the  surmise  which  I  have  already  ex- 
pressed, that  the  Roman  law  took  practically  no  cognizance  of 
the  physician  as  an  expert.  In  view  of  the  extraordinary  pov- 
erty of  medical  and  psychiatric  knowledge  that  existed  even  at 
the  time  of  Caesar,  this  is  quite  comprehensible;  and  the  re- 
striction of  the  exercise  of  the  art  of  healing  to  slaves  clearly 
shows  the  low  degree  of  esteem  in  which  it  was  held.  Even  at  a 
later  period,  when  Greek  physicians  in  Rome  were  active  as  the 
physicians  of  the  state  and  were  organized  as  a  medical  body, 
medical  expertism  had  no  standing  at  all  before  the  courts.  This 
is  all  the  more  astonishing  because  the  Roman  laws,  as  previously 
stated,  treated  the  question  of  responsibility  in  accordance  with 
certain  definite  rules  and  gave  careful  attention  to  other  details 
of  forensic  medicine.  It  is  quite  possible  that  the  disregard  for 
medical  expertism  was  partly  due  to  the  fact  that  expert  opin- 
ions were  often  directly  at  variance  with  each  other,  just  as  they 
are  to-day,  and  that  the  medical  questions  JB¥©rYJe^  in  the  cases 
submitted  for  judicial  decision  consequently  became  obscured 
rather  than  illuminated. 

Galen's  treatise  on  the  "Recognition  of  Simulation,"  gener- 
ally believed  to  be  the  earliest  medico-legal  work,  in  no  way 
mentions  the  legal  significance  of  mental  expertism.  From  the 
body  of  Roman  law  compiled  and  annotated  at  the  command 
of  the  Emperor  Justinian,  we  learn  simply  that  the  medical  and 
psychiatric  doctrines  expounded  by  medical  experts  merited  con- 
sideration by  the  judge,  but  that  he  was  in  no  way  bound  by 


36       THE  UNSOUND  MIND  AND  THE  LAW 

them  in  deciding  the  question  of  responsibility.  Simulation  of 
insanity  seems  to  have  been  very  infrequent  at  that  time,  a  fact 
explained  by  the  state  of  culture  then  current.  Simulation  of 
slight  disorder  would  not  have  averted  punishment,  while  sim- 
ulation of  severe  psychosis  would  have  created  suspicion  of 
demonic  possession. 

This  state  of  affairs  persisted  throughout  the  entire  middle 
ages  and  did  not  improve  even  with  the  introduction  of  the  leg- 
islation dealt  with  in  the  "Carolina"  (1532).  Just  as  Galen 
had  done,  so  Zachias  in  the  seventeenth  century  gave  specific  di- 
rections for  unmasking  simulation.  According  to  him,  no  form 
of  shamming  is  more  difficult  to  unmask  than  that  of  insanity. 
Among  the  notable  personages  who  had  simulated  insanity, 
Zachias  named  David,  Odysseus,  Solon  and  Brutus.  He  desig- 
nated an  ashiness  and  pallor  of  the  skin,  together  with  deeply 
sunken  eyes,  as  among  the  signs  that  differentiated  actual  from 
simulated  melancholia.  True  mania  was  said  to  be  character- 
ized by  a  livid  color  and  protruding  eyes.  Where  simulation 
was  suspected,  Zachias  recommended  that  the  emotions  be  arti- 
ficially aroused,  a  procedure  supposed  to  be  impossible  in  persons 
who  were  actually  insane.  The  older  authors,  moreover,  were 
acquainted  with  the  fact  that  conditions  of  ecstasy  were  depend- 
ent either  upon  insanity  or  upon  wilful  deception,  and  further- 
more that  persons  habitually  simulating  pathological  mental 
states  easily  become  a  prey  to  actual  insanity  as  a  result  of  their 
perverted  efforts.  To-day  we  know  the  majority  of  simulators 
are  actually  mentally  disturbed  and  that  their  simulation  of 
disease  is  no  more  than  a  manifestation  of  their  psychopathic 
constitution. 

This  fact,  of  such  eminent  importance  in  forensic  psychiatry, 
had  already  ])fceu  ^cognized  and  fully  explained  by  Arnold  in 
1784  and  Metier  in  1803.  Notwithstanding  such  individual 
instances  of  enlightenment,  the  majority  of  physicians,  even  into 
the  nineteenth  century,  believed  the  best  means  for  unmasking 
attempted  simulation  was  a  good  beating ;  and  very  few  of  them, 
when  endeavoring  to  balk  such  attempts  at  deception,  thought 
for  one  moment  of  looking  for  the  presence  of  objective  symp- 
toms, not  dependent  upon  the  patient's  volition.  If  we  go  back 
still  another  century,  we  find  the  simulants  occupying  a  still 
more  precarious  position.    When  they  were  successful,  their  skill 


HISTORICAL  RETROSPECT       37 

was  the  cause  of  their  being  sent  to  the  fire  heap,  on  the  ground 
of  possession  by  evil  spirits ;  when  unsuccessful,  their  awkward- 
ness brought  upon  them  the  most  barbarous  punishment.  Even 
when  the  suspicion  of  simulation  was  unfounded,  the  suspects 
were  not  safe  from  brutal  treatment.  The  mediaeval  spirit 
which  permitted  Luther  to  propose  drowning  an  idiotic  child  had 
not  yet  ceased  to  exist.  I  have  already  given  an  example  of  this 
spirit  by  showing  how,  as  late  as  the  middle  of  the  eighteenth 
century,  the  medical  faculty  of  Wurzburg  passed  expert  judg- 
ment upon  the  mental  state  of  a  "  witch. ' '  Whenever  in  a  given 
instance  manifest  symptoms  of  idiocy  or  mania  did  not  exist 
the  forensic  psychiatrist  usually  failed  to  recognize  the  presence 
of  disease,  to  say  nothing  of  his  inability  to  unveil  any  attempt 
at  simulation.  At  that  time,  as  previously,  the  dangerous  insane, 
even  when  recognized  as  such,  were  incarcerated  together  with 
criminals  or  placed  in  strait- jackets,  quieted  by  the  rapid  rota- 
tion of  the  notorious  gyratory  chair,  scourged  with  whips  or 
immersed  in  ice  cold  water.  There  did  exist  scientific  psychiat- 
ric work  and  scientific  psychiatric  workers;  but  unfortunately 
progress  in  anatomy  and  the  physiology  of  brain  and  nervous 
system  did  not  pass  beyond  considerations  of  a  purely  theoreti- 
cal nature. 

Stahl  and  his  pupils  attempted  to  put  their  ideas  to  practical 
use,  but  could  not  carry  out  their  humane  endeavors  because 
there  were  no  institutions  for  the  reception  and  treatment  of 
the  insane,  no  practical  test  could  be  made  as  to  whether  it  was 
possible  to  improve  or  cure  states  of  mental  disorder  without 
measures  of  restraint,  and  consequently  the  value  of  the  new 
investigational  trend  could  not  be  demonstrated.  The  fact  that 
all  progress  was  upon  the  side  of  theory  and  was  not  of  prac- 
tical moment  was  due  not  only  to  a  persistence  of  the  mediaeval 
spirit  but  also  to  the  appearance  of  that  tendency  in  natural 
philosophy  which  still  has  a  certain  amount  of  support  to-day 
under  the  designation  ' '  vitalism. ' '  The  over-zealous  enthusiasm 
of  Paracelsus  and  other  revolutionary  minds  of  the  sixteenth 
and  seventeenth  centuries  in  attempting  to  annihilate  every- 
thing previously  existing  and  to  place  the  whole  of  medicine 
upon  a  new  basis  is  convincing  proof  of  the  correctness  of  the 
saying  that  ' '  each  extreme  to  equal  danger  tends. ' '  Up  to  that 
time  the  ultimate  causes  of  the  manifestations  of  life  had  been 


38       THE  UNSOUND  MIND  AND  THE  LAW 

relegated  to  the  transcendental  world,  but  now  an  attempt  was 
made  to  explain  all  vital  processes,  physical  as  well  as  psychic, 
by  the  laws  of  nature.  Correct  as  this  principle  was  in  itself, 
it  was  doomed  to  early  disaster.  In  order  to  appreciate  this 
apparent  paradox  we  have  but  to  recall  that  the  physics  and 
chemistry  of  that  period  had  not  yet  passed  through  the  first 
stages  of  their  development  and  that  even  such  geniuses  as 
Paracelsus  and  Haller,  embodiments  of  the  entire  knowledge  of 
their  time,  had  but  a  feeble  conception  of  the  laws  and  forces 
of  nature.  Necessarily,  because  of  the  inadequacy  of  the  aids  at 
the  disposal  of  science  for  purposes  of  investigation,  the  boun- 
daries of  the  knowable  were  very  much  more  restricted  than  they 
are  at  present,  and  any  one  who  was  no  longer  content  with  a 
mere  establishment  of  facts  but  who  demanded  an  explanation  of 
their  causal  relations  soon  arrived  at  the  point  where  he  could 
obtain  no  answer  other  than  "We  do  not  know."  On  account 
of  the  meagerness  of  actual  knowledge  concerning  the  laws  of 
nature,  there  remained  so  much  that  could  not  be  explained 
that  recourse  was  had  to  the  "vital  spirits"  which  had  played 
so  important  a  role  during  the  classic  period  of  antiquity  under 
the  name  of  "pneuma." 

It  was  not  yet  time  to  comprehend  the  world's  development 
from  the  laws  of  nature  alone.  The  premature  application  of 
the  fragments  of  physical  and  chemical  knowledge  of  the  proc- 
esses of  life  and  other  phenomena  could  not  but  produce  evil 
results,  and  there  still  remained  an  unknown  quantity  which, 
notwithstanding  all  precise  investigation,  could  not  be  rescued 
from  obscurity.  This  unknown  quantity  was  called  "vital 
force. ' '  Mysticism  and  speculation  soon  had  free  rein  as  a  result. 
Vital  force  represented  to  each  individual  whatever  he  was 
pleased  to  consider  it.  Fortunately,  however,  science  had  by  this 
time  become  far  too  skeptical  to  allow  itself  to  be  swayed  by 
theosophic  enthusiasm  and  visionary  notions.  Therefore  it  was 
only  upon  the  investigations  of  those  physicians  who  believed 
the  mind  to  be  something  unmaterial,  and  its  disorders  to  be  the 
result  of  sin,  that  vitalism  exerted  its  paralyzing  influence. 
"Where  so  insupportable  a  premise  existed,  a  search  for  the  causes 
of  disease,  or  for  measures  to  prevent  or  remove  them,  was  of 
course  futile.  Nevertheless,  as  late  as  the  middle  of  the  last  cen- 
tury we  find  the  Bavarian  clinician  von  Ringseis  (1785-1880) 


HISTORICAL  RETROSPECT       39 

recommending  propitiation  of  God  as  the  best  means  for  curing 
disease.  Other  clinicians,  like  Heinroth  and  Ideler.  of  Berlin, 
did  not  go  quite  so  far,  but  even  they  considered  the  mind  as 
the  principle  which  ruled  the  body,  and  the  psychoses,  therefore, 
as  something  entirely  different  from  bodily  disease.  In  these 
views  we  see  the  influence  exerted  by  Schelling's  "Philosophy 
of  Nature,"  which  declared  nature  and  mind  to  be  identical. 
It  was  this  doctrine  that  caused  a  schism  in  the  ranks  of  the 
vitalists.  The  thoughts  of  the  more  conservative  continued  to 
be  governed  by  a  temperate,  quiet,  observation  of  facts;  for 
them  it  was  the  body  that  determined  the  functions  of  the  mind, 
and  the  latter  therefore  were  dependent  upon  their  material 
basis,  more  particularly  upon  the  composition  of  the  brain  and 
nervous  system.  Inasmuch  as  experimental  (physiological) 
psychology  did  not  exist  a  century  ago,  no  psychic  manifesta- 
tions (reflex  action,  apperception,  thought,  association  of  ideas, 
etc.)  could  be  understood.  All  these  manifestations  were  at- 
tributed by  the  temperate  vitalists  to  the  action  of  "vital  force." 
In  this  they  were  still  very  far  distant  from  the  radicals  who 
ascribed  all  unexplained  vital  processes  to  transcendental  causes 
The  temperate  element,  moreover,  regarded  vital  force  as  being 
subject  to  the  laws  of  nature.  Their  fundamental  error  con- 
sisted in  believing  that  everything  that  they  had  been  unable  to 
recognize  belonged  to  the  category  of  the  unrecognizable. 
Therein  lies  the  essential  difference  between  the  scientific  views 
of  those  times  and  of  the  present.  Many  things  still  elude  our 
sense  perceptions.  I  need  but  refer  to  the  problems  of  the 
earliest  production  of  life.  We  regard  it  as  certain  that  the 
enigmatical  manifestations  of  early  mental  life  are  based  upon 
natural  causes;  but  we  do  not  maintain  these  causes  to  be  un- 
recognizable. We  merely  assert  that  they  have  not  yet  been 
recognized.  The  mere  fact  that  something  has  not  yet  been 
recognized  does  not  mean  it  is  actually  unrecognizable.  Many 
processes  of  nature  which  our  forefathers  regarded  as  being 
hidden  behind  an  enigmatical  veil  can  to-day  be  traced  to  their 
ultimate  causes;  similarly  our  descendants  with  their  improved 
means  of  investigation,  will  be  able  to  furnish  precise  proof  of 
the  cause  of  those  phenomena  of  nature  that  are  still  unrecog- 
nizable to  us. 

The  moderate  vitalists  of  whom  we  have  just  been  speaking, 


40       THE  UNSOUND  MIND  AND  THE  LAW 

including  Haller,  Reil,  Johannes  Mueller,  and  Oken,  the  founder 
of , the  society  of  German  naturalists  and  physicians,  contrasted 
sharply  with  all  other  vitalists.  The  latter  looked  upon  the 
mind  as  the  governing  principle  of  the  body  and  endeavored  to 
explain  all  physical  occurrences  by  means  of  psychic  processes. 
It  is  indisputable,  of  course,  that  psychic  functions  do  exert  a 
marked  influence  upon  the  activity  of  the  body.  Elsewhere  I 
have  demonstrated  how  mere  imagination  may  not  only  produce 
functional  disturbances,  but  may  even  remove  such  disorders 
when  they  exist,  a  fact  which  becomes  very  evident  in  those 
paralyses  which  continue  only  so  long  as  the  patient's  attention 
is  directed  toward  them,  but  seem  to  disappear  as  soon  as  it  is 
diverted  into  other  channels.  But  even  if  we  must  ascribe  to 
the  mind  a  certain  power  over  the  body,  we  can  by  no  means 
endorse  the  contention  of  the  vitalists,  that  the  spirit  (mind) 
is  the  carrier  of  life.  It  is  essential  to  grasp  the  harmfulness 
and  absurdity  of  this  theory  in  order  that  we  may  comprehend 
why  psychology  and  psychiatry  until  the  second  half  of  the 
last  century  were  unable  to  reap  any  benefit  from  the  fact,  long 
theoretically  recognized,  that  diseases  of  the  mind  are  diseases 
of  the  brain.  The  same  theory,  furthermore,  explains  why 
psychiatric  investigation  was  in  no  way  benefited  by  any  of 
the  new  medical  systems  which  arose  from  the  fermenting  leaven 
of  old  and  new  systems  and  views  of  the  eighteenth  century. 
Of  these  systems,  that  of  Hahneman  was  the  most  aggressively 
representative  of  vitalistic  views.  Assuming  the  existence  of  a 
force  without  matter,  and  believing  vital  force  to  be  solely 
spiritual  in  character,  he  maintained  that  the  diseases  caused 
by  alterations  of  vital  force  could  not  be  demonstrated  either 
etiologically  or  symptomatically,  and  that  it  was  therefore  not 
worth  while  to  endeavor  to  ascertain  the  cause  of  diseases, 
whether  mental  or  physical,  or  to  endeavor  to  recognize  and 
demonstrate  their  manifestations. 

These  various  historical  facts  demonstrate  how,  until  well  into 
the  nineteenth  century,  all  recognition  of  the  forms  of  manifesta- 
tions of  the  different  psychoses  was  of  the  most  primitive  kind, 
and  why  the  brutal  and  senseless  treatment  accorded  to  the 
insane  was  the  result  of  crass  ignorance.  But  even  during  the 
times  of  the  most  intense  superstition  there  were  many  physi- 
cians who,  notwithstanding  they  were  similarly  prejudiced,  were 


HISTORICAL  RETROSPECT  41 

governed  to  such  an  extent  by  their  humane  feelings  that  they 
considered  the  insane  as  unfortunate,  pitiable  beings  who, 
whether  or  not  their  deplorable  state  was  caused  by  an  "evil 
spirit,"  certainly  were  sick  and  required  mental  aid. 

To  England  must  be  awarded  the  credit  of  having  led  all 
other  countries  in  the  humane  care  of  the  insane.  As  early  as 
1547  a  former  convent  in  Bedlam  (Ireland)  was  transformed 
into  an  asylum  for  the  insane.  Not  until  two  hundred  years 
later  was  the  first  public  insane  asylum  organized  in  St.  Luke 's 
Hospital  in  London.  Psychiatry  was  benefited  to  a  far  greater 
extent  by  the  organization  of  numerous  private  insane  asylums, 
for  the  most  part  founded  by  the  pupils  of  Cullen.  Among 
these  were  the  asylums  founded  by  Thomas  Arnold  in  1816  at 
Leicester,  by  "William  Perfect  in  1818  at  Westmalling,  Kent,  and 
by  the  Scotchman,  Alexander  Crichton,  in  1820  at  London. 
Crichton  attributed  the  psychoses  to  physical  and  mental  causes, 
while  Perfect  laid  more  stress  upon  the  somatic  origin  and  upon 
the  hereditary  transmissibility  of  mental  disorder. 

In  France  the  deplorable  state  of  psychiatry  continued  to 
persist.  It  was  not  until  the  occurrence  of  the  Revolution  and 
the  proclamation  of  the  "rights  of  man"  that  the  unfortunate 
insane  were  released  from  the  prisons  in  which  they  had  been 
incarcerated.  The  impetus  to  this  action  was  given  by  Pinel, 
who  in  the  face  of  personal  danger  forced  the  assembly  to  per- 
mit the  insane  to  be  dissociated  from  their  criminal  compan- 
ions. Pinel  found  a  most  worthy  successor  in  his  pupil  Esquirol, 
director  of  the  Salpetriere,  in  1811,  Inspector  General  of  Medi- 
cal Instruction  in  1823  and  Director  of  the  Insane  Asylum  at 
Charenton  in  1826.  Esquirol  devoted  his  entire  life  to  the  study 
of  insanity.  The  foundation  of  the  first  psychiatric  clinic  in 
Paris  in  1817  was  due  to  his  efforts.  Here  for  the  first  time  it 
was  made  possible  for  a  physician  by  means  of  methodical,  the- 
oretical and  practical  instruction,  to  acquire  at  least  a  funda- 
mental conception  of  psychiatry. 

At  the  beginning  this  instruction  was  so  arranged  that  the 
theoretical  part  was  embodied  in  the  university  schedule.  The 
practical  demonstration  took  place  in  the  asylum.  Where  no 
asylum  existed  in  a  university  town,  the  student's  knowledge 
necessarily  was  entirely  theoretical.  Moreover,  theoretical  psy- 
chiatry, at  that  time  of  transition,  continued  to  bear  a  marked 


42       THE  UNSOUND  MIND  AND  THE  LAW 

philosophic  impress,  and  in  some  universities  this  instruction 
was  given  not  by  a  teacher  of  medicine  but  by  a  member  of  the 
philosophical  faculty.  Not  until  the  middle  of  the  last  century- 
was  a  psychiatric  university  clinic  organized,  in  which  the  stu- 
dents in  medicine  were  taught  to  lay  aside  all  prejudice  and  to 
look  upon  mental  disease  as  disease  of  the  brain  and  nervous 
system.  From  that  time  on  the  clouds  that  had  obscured  all 
psychiatric  teachings  began  to  lift.  The  scholastic  doctrines 
that  psychoses  could  be  influenced  by  psychic  remedies  alone 
had  at  last  been  finally  overcome.  The  veil  which  philosophy 
and  theology  had  for  centuries  spread  over  an  understanding 
of  all  mental  processes  was  entirely  raised  by  the  influence  of 
theoretical  and  practical  instruction  in  the  university  clinics. 
From  that  time  on  every  student  of  average  intelligence  recog- 
nized that  mental  disorders  represented  something  entirely  dif- 
ferent from  what  the  older  theory  had  assumed  them  to  be.  Ex- 
perimental pathology,  with  its  methods  of  exact  investigation, 
soon  succeeded  in  removing  the  last  persisting  doubt,  and  showed 
that  no  positive  knowledge  could  be  obtained  by  a  study  of 
psychoses  according  to  a  preconceived  theory,  but  that,  on  the 
contrary,  theory  must  be  deduced  from  clinical  observations, 
from  the  results  of  experimental  investigation  alone.  A  worthy 
imitator  of  Esquirol  was  Ferrus,  who  associated  with  Pinel  as 
physician  to  the  Salpetriere  in  1913,  later  became  physician-in- 
chief  to  the  Hospital  at  Bicetre,  and  still  later  inspector  of 
French  asylums  for  the  insane,  into  which  he  introduced  agri- 
cultural occupation  of  the  patients  as  a  means  of  treatment. 

The  rapid  growth  of  the  French  School  of  psychiatry  was  due 
entirely  to  the  employment  as  a  means  of  investigation  of  patho- 
logical anatomy  combined  with  precise  clinical  observation.  Bi- 
chat,  although  himself  not  an  alienist,  was  one  of  the  leaders  in 
this  movement.  His  studies  of  the  brain  and  nervous  system 
resulted  in  valuable  disclosures,  which  were  supplemented  by 
the  teachings  derived  from  the  autopsies  regularly  made  upon 
the  bodies  of  patients  who  had  died  during  a  pronounced  psy- 
chosis. While  Bichat's  work  was  going  on  in  France,  the  efforts 
of  Reil  in  Germany  and  of  Bell  in  England  were  proving  of 
great  service  to  psychiatry.  Following  these  precepts,  Chiarugi, 
in  1823,  published  a  text-book  of  mental  disease  based  essentially 
upon  results  obtained  from  pathological  anatomy,  a  basis  which 


HISTORICAL  RETROSPECT  43 

must  be  characterized  as  premature,  because  even  to-day  there  is 
lacking  a  clear  understanding  of  the  structural  changes  in  the 
central  nervous  system  that  are  associated  with  mental  disorder. 

Working  together,  Spurzheim  and  Gall  arrived  at  the  conclu- 
sion, at  once  endorsed  by  French  investigators,  that  mental  dis- 
orders should  be  considered  not  only  diseases  of  the  brain  but 
also  that  they  were  bound  to  certain  definite  regions  of  that 
organ.  This  principle  of  localization  attained  complete  ascend- 
ency after  two  pupils  of  Spurzheim,  Voisin  and  Georget,  had 
declared  the  "alteration"  which  arose  in  any  part  of  the  brain 
to  be  the  starting  point  of  the  psychosis.  Among  the  pupils  of 
Esquirol,  who  aided  the  progress  of  psychiatry  through  their 
independent  investigations,  unhampered  by  theoretical  assump- 
tions, we  must  especially  mention  Foville,  Calmeil,  Falret  (father 
and  son),  Morel,  du  Boismont  and  Trelat. 

Reil,  the  founder  of  the  newer  period  of  psychiatry  in  Ger- 
many, has  already  been  mentioned.  He,  like  Pinel,  was  first  in- 
spired to  take  up  his  psychiatric  work  by  the  deplorable  condi- 
tions then  existing  in  all  asylums  for  the  insane.  Later  his  in- 
terest in  this  branch  of  medicine  found  full  occupation  in  his 
investigations  of  the  structure  of  the  brain.  Eeil's  endeavors 
to  establish  hospitals  for  the  mentally  disordered  were  frus- 
trated by  unfavorable  political  conditions,  the  concentration  of 
endeavor  to  free  Germany  from  the  Napoleonic  yoke,  and  by 
his  premature  death.  The  most  important  psychiatric  repre- 
sentatives of  Reil's  teachings  are  Horn  and  Nasse.  Far  more 
successful  than  the  work  of  Reil,  which  for  the  most  part  was 
theoretical  in  character,  were  the  efforts  of  Langermann,  who 
advanced  the  practical  side  of  psychiatry.  His  endeavors  were 
aided  by  the  reestablishment  of  peaceful  conditions  in  Germany 
and  by  the  foundation  of  appropriate  institutions  for  the  care 
of  the  insane. 

Nor  had  other  countries  been  inactive.  In  Holland,  Schroeder 
van  der  Kolk,  and  in  Belgium,  Guislain,  were  the  standard- 
bearers  of  modern  psychiatry.  Most  decisive  influence  upon  the 
care  of  the  insane  was  exerted  by  the  Scotchman,  Connolly,  the 
originator  of  the  non-restraint  system. 

The  pronounced  victory  that  the  inductive  method  of  medical 
investigation  gained  about  the  time  of  Virchow  's  cellular  pathol- 
ogy caused  psychiatry  to  take  rank  as  one  of  the  natural  sci- 


44       THE  UNSOUND  MIND  AND  THE  LAW 

ences.  Through  the  work  of  Fechner  and  Weber,  the  science  of 
psychology  and  that  of  physiology  of  the  brain  and  nervous 
system  had  been  entirely  transformed,  and  it  had  been  shown 
by  experimental  means  that  all  psychic  functions  were  accom- 
panied by  physical  alterations,  hence  that  all  psychic  manifesta- 
tions of  life,  under  normal  as  well  as  under  pathological  con- 
ditions, were  dependent  upon  physical  processes.  The  physiolog- 
ical method  of  psychic  investigation  was  still  further  developed 
and  elaborated  through  the  comprehensive  work  of  Wundt,  so 
that  to-day  this  method  of  investigation  merits  particular  con- 
sideration as  representing  the  basis  upon  which  rests  not  only 
psychiatry  but  also  pedagogic  psychology.  In  the  course  of  my 
treatise  it  will  be  necessary  to  refer  repeatedly  to  the  methods 
of  examination  elaborated  by  Wundt  and  his  coadjutors.  Among 
the  older  psychiatrists,  those  who  have  laid  special  stress  upon 
the  somatic  origin  of  mental  disorder  and  who  have  strenuously 
opposed  the  notion  that  disease  of  the  mind  is  no  different  from 
disease  of  the  body,  I  would  mention  the  names  of  Damerow, 
Griesinger,  K.  W.  M.  Jacobi,  Jessen  and  Fleming.  Whatever 
else  may  be  said  about  the  development  of  modern  psychiatry 
constitutes  part  of  the  happenings  of  to-day,  so  I  may  be  per- 
mitted to  confine  myself  to  a  mere  mention  of  the  important 
stages.  The  system  of  family  care  of  the  quiet  insane  and  their 
agricultural  employment  that  has  existed  in  the  Belgian  village 
of  Gheel  since  the  twelfth  century  has  in  recent  years  been 
successfully  adopted  in  many  other  places.  Of  course,  family 
care  and  agricultural  colonies  alone  will  not  suffice,  and  institu- 
tions with  closed  doors  are  still  a  necessity.  From  these,  how- 
ever, practically  all  measures  of  restraint  have  been  banished. 

To-day  we  know  that  the  brain,  like  every  other  organ,  may 
become  diseased  either  primarily  or  secondarily.  It  is  not  nec- 
essary that  such  disease  should  be  accompanied  by  psychic  dis- 
order. Every  psychosis  or  neuro-psychosis,  however,  must  be 
accompanied  by  affection  of  the  brain  and  its  conducting  tracts. 
We  know  that  intoxication  of  various  kinds  may  be  followed  by 
exhausting  transitory  mental  disorder  which  later  disappears, 
unless  permanent  changes  of  the  brain  substance  have  been  pro- 
duced. But  we  also  know  that  a  general  constitutional  disease 
of  the  blood  may  so  vitiate  this  fluid  that  the  nutrition  of  the 
brain  will  be  damaged.     In  such  cases,  no  demonstrable  lesion 


HISTORICAL  RETROSPECT       45 

will  be  found,  either  during  life  or  upon  autopsy ;  as  paresis  is 
the  mental  disease  in  which  organic  changes  are  most  pro- 
nounced, it  is  this  affection  which  has  been  most  carefully 
studied.  Westphal  was  the  first  to  describe  the  ascending  form 
of  this  disease,  also  known  as  tabo-paresis.  Gudden  also  has 
occupied  himself  most  seriously  with  this  psychosis  and  by  means 
of  animal  experiments  has  demonstrated  the  results  following 
destruction  of  the  nerve  endings  in  the  brain.  The  very  recent 
discovery  made  by  Noguchi  and  confirmed  by  other  investigators, 
that  the  spirochetes  of  syphilis  are  present  in  the  brains  of  gen- 
eral paretics,  opens  an  entirely  new  vista  in  regard  to  the  nat- 
ural course,  pathological  anatomy  and  treatment  of  the  disease. 
While  it  had  long  been  suspected  that  the  Treponema  pallidum 
(Spirochaeta  pallida  or  spirochsetes)  was  the  essential  productive 
factor  in  paresis,  the  proof  of  its  existence  in  the  brain  now 
renders  the  problem  of  future  therapeutic  work  much  more 
precise  and  hopeful. 

Great  progress  has  been  made  through  the  Mendelian  law  of 
heredity.  But,  because  of  a  lack  of  family  trees  and  other  sta- 
tistical foundations,  we  are  yet  unable  practically  to  apply  this 
law  in  such  a  manner  that  an  amelioration  of  the  race  through 
elimination  of  inferior  generative  qualities  can  be  obtained. 
More  recently  literature  has  been  replete  with  discussions  for 
and  against  these  ' '  eugenistic ' '  endeavors  and,  among  other 
things,  instances  have  been  published  of  a  robust,  healthy  woman 
who,  in  accordance  with  the  law  of  inheritance,  should  bear  a 
normal  offspring,  having  brought  into  the  world  a  dead  ananceph- 
alus,  while,  upon  the  other  hand,  an  anaemic,  crippled,  rheu- 
matic woman  bore  a  strong,  healthy  child.  We  therefore  pos- 
sess no  criterion  by  means  of  which  we  could  decide  which  indi- 
viduals should  be  permitted  to  propagate — that  is,  to  marry — 
and  which  ones  should  be  forbidden  to  do  so.  Regarding  the 
degeneracy  that  is  said  to  threaten  the  race  in  consequence  of 
inheritance  of  mental  disease,  we  certainly  should  not  be  unduly 
apprehensive,  because  the  transmission  of  the  germs  of  degen- 
eracy is  never  accomplished  alone.  With  them,  in  fact,  there  are 
always  transmitted  germs  of  regeneracy  which  serve  to  neutral- 
ize their  ill  effects. 

A  much  debated  question  is  the  one  regarding  the  point  of 
view  that  is  to  govern  the  systematic  classification  of  the  psy- 


46       THE  UNSOUND  MIND  AND  THE  LAW 

choses  and  neuro-psychoses.  Kraepelin  considers  our  present 
classification  of  disease  as  a  mere  attempt  to  present  temporarily 
a  certain  part  of  our  observations  in  the  form  of  material  for 
clinical  instruction.  Very  justly  lie  points  out  that  a  complete 
knowledge  of  all  the  details  that  the  study  of  pathology,  anatomy, 
etiology  and  symptomatology  could  furnish  would  necessarily 
make  any  classification  of  mental  disorders  constructed  upon 
the  basis  of  any  one  of  these  divisions  accord  essentially  with 
any  other  classification  constructed  upon  the  basis  of  the  knowl- 
edge derived  from  the  study  of  the  other  fields;  for  it  must  be 
clear  that  diseases  resulting  from  the  same  causes  must  under 
the  same  conditions  always  show  the  same  clinical  manifesta- 
tions and  the  same  pathological  alterations.  Hence  there  could 
be  but  one  system  of  classification,  no  matter  which  point  of 
view  had  governed  us  in  its  construction.  As  yet,  however,  our 
knowledge  has  not  arrived  at  that  stage  of  perfection.  Neither 
pathological  anatomy,  nor  etiology,  nor  symptomatology  is  able 
to  furnish  a  reliable  basis  for  a  classification  of  the  different 
forms  of  mental  disease.  In  the  majority  of  instances  the  causes 
of  insanity  remain  obscure  With  our  present  means  of  investi- 
gation, the  autopsy  in  only  a  few  instances  can  give  us  precise 
information  regarding  the  organic  changes  apparently  indicated 
by  the  clinical  symptoms.  Certainly  there  are  no  individual  evi- 
dences of  mental  disease  that  are  unmistakable.  For  purposes 
of  classification  we  must  have  before  us  the  entire  picture  of  a 
disease,  as  shown  by  its  course  from  beginning  to  end,  because 
that  enables  us  to  register  similar  observations  as  belonging  to  a 
certain  category,  and  warrants  us  in  arranging  the  various  forms 
of  insanity,  according  to  their  similarities  and  dissimilarities, 
into  a  definite  system,  with  classes  or  subdivisions.  It  must  be 
admitted  that  variations  in  the  mode  of  origin  of  similar  forms 
of  insanity  may  remain  hidden  or,  on  the  other  hand,  that  simi- 
lar modes  of  origin  of  apparently  dissimilar  forms  of  insanity 
may  not  be  recognized,  so  that  instances  of  disease  naturally 
belonging  together  are  classified  separately,  while  others  which 
should  be  separate  are  classed  together.  Some  do  not  fit  into 
any  one  of  our  classifications  and  cannot  be  made  to  do  so. 
Life,  in  health  and  disease,  manifests  itself  under  such  endlessly 
changing  forms  and  transitions  that  every  scheme  of  classifica- 
tion must  remain  more  or  less  incomplete.     Psychiatry,  like 


HISTORICAL  RETROSPECT       47 

every  other  science  that  is  not  yet  completed,  must  not  be  al- 
lowed to  become  riveted  to  any  one  "system"  which,  after  all, 
can  merely  serve  to  enable  us  to  express  a  certain  stage  of  our 
knowledge.  Almost  every  author  groups  the  psychoses  differ- 
ently, and  almost  every  country  has  its  own  special  "system." 

The  physical  changes  constituting  the  basis  of  the  psychoses 
are  as  yet  only  partly  known.  Nor  do  we  know  precisely  how 
the  congenital  weakness  or  inferiority  of  the  brain  which  we 
look  upon  as  a  disposition  to  disease  finds  its  expression  in  the 
cell  structure.  For  this  reason  we  are  still  obliged  to  designate 
the  various  forms  of  psychoses  by  terms  that  characterize  the 
psychic  aspect  of  the  disease,  whereas,  as  has  been  proposed 
by  various  writers,  it  would  be  far  more  correct  to  designate 
the  diseases  by  names  that  would  emphasize  the  physical  mani- 
festation of  the  pathological  process.  Only  if  this  were  done 
would  it  become  clear  to  every  layman  that  mental  diseases 
are  to  be  regarded  in  precisely  the  same  light  as  tuberculosis, 
cancer,  nephritis  or  any  other  ordinary  disease.  It  is  impos- 
sible to  enumerate  all  the  investigators  who  by  their  anatomi- 
cal, physiological  or  clinical  work  have  aided  in  disentangling 
the  relations  that  exist  between  morbid  manifestations  of  nerve 
activity  and  corresponding  changes  in  bodily  functions.  But  I 
must  mention  advances  that  have  been  of  particular  signifi- 
cance in  the  development  of  forensic  psychiatry. 

Increased  precision  in  the  recognition  of  mental  disorders 
has  made  it  necessary  to  frame  a  formal  statutory  expression  of 
the  manner  of  judging  the  actions  of  mentally  abnormal  indi- 
viduals. "We  can  have  no  better  pattern  than  that  furnished  by 
the  civil  and  criminal  statutes  of  the  German  Empire.  These 
assume  the  existence  of  diminished  responsibility  or  restricted 
freedom  of  the  will  in  the  feeble-minded,  the  alcoholic  and  the 
squanderer.  Persons  in  these  groups,  on  becoming  of  age,  may 
be  placed  under  guardianship  and  considered  as  children  in  the 
eyes  of  the  law.  If  they  have  committed  any  punishable  act 
the  full  severity  of  the  law  is  not  meted  out  to  them.  More- 
over, according  to  the  same  statutes,  an  unlawful  act  is  not 
punishable  if  the  offender,  when  committing  the  act,  was  in  a 
state  of  unconsciousness  or  of  pathological  disorder  of  mental 
activity  through  which  freedom  of  voluntary  determination  was 
precluded.     The  Anglo-Saxon  law  as  applied  in  similar  cases 


48   THE  UNSOUND  MIND  AND  THE  LAW 

has  certain  shortcomings.  Above  all,  it  recognizes  no  "dimin- 
ished" responsibility.  It  regards  a  person  either  as  being  men- 
tally sound  and  entirely  responsible,  or  else  as  being  mentally 
diseased  and  not  at  all  responsible.  The  fact  that  numerous 
intermediary  degrees  may  be  recognized,  though  often  only  with 
the  utmost  difficulty,  is  disregarded  by  the  Anglo-Saxon  law. 
Accordingly  a  psychically  inferior  law-breaker  either  is  punished 
too  severely  or  escapes  punishment  entirely.  The  requirement 
that  a  jury  bring  in  a  verdict  for  or  against  the  guilt  of  an 
insane  person  accused  of  committing  an  illegal  act  must  place 
every  one  concerned  in  a  most  extraordinary  position.  Every 
illegal  act  carries  with  it  a  demand  for  expiation,  and  if  the 
jurors  return  a  verdict  against  the  defendant,  it  leads  in  the 
one  case  to  the  extraordinary  declaration  that  the  insane  person 
is  guilty  of  having  committed  a  crime,  while  in  the  other  case 
the  admission  is  made  that  no  punishment  can  be  instituted 
although  a  crime  has  been  committed.  This  dilemma  is  avoided 
by  the  German  law,  which  holds  it  impossible  for  an  insane  per- 
son to  commit  a  punishable  act.  Consequently  when  the  psy- 
chiatric experts  have  presented  convincing  proof  of  the  exist- 
ence of  insanity,  the  district  attorney  in  the  German  court  with- 
draws his  application  for  punishment  and  the  indictment  is 
annulled.  Thus  the  matter  is  settled  and  the  jury  need  not  de- 
cide upon  the  question  of  "guilt"  or  "innocence."  It  is  true 
this  procedure  is  facilitated  by  the  fact  that  the  psychiatric  ex- 
pert is  a  public  official,  who  has  no  interest  either  in  the  con- 
viction or  the  acquittal  of  the  accused.  In  this  country,  however, 
the  prosecution  and  the  defense  each  place  an  expert  in  the 
field;  and  the  expert  for  the  prosecution  being  quite  as  much 
interested  in  proving  the  accused  sane  as  the  expert  for  the  de- 
fense is  in  proving  him  insane,  there  usually  arises  a  verbal 
conflict  in  which  each  side  strives  to  win  the  jury  over  to  its 
view. 

The  German  law  is  far  more  representative  of  the  present 
state  of  psychiatry.  This  is  shown  particularly  by  its  attitude 
toward  the  self-accusations  of  the  insane.  Not  infrequently  per- 
sons who  have  been  sentenced  to  severe  punishment  because 
they  admitted  guilt  have  afterward  been  proven  innocent  of  the 
crime  and  it  was  then  realized  that  such  judicial  errors  were 
dependent  upon  the  insanity  of  the  accused.     The  actual  med- 


HISTORICAL  RETROSPECT  49 

ical  state  of  the  prisoner  may  not  be  recognized  for  a  long  time 
if  his  demeanor  does  not  attract  special  attention  or  if  he 
knows  how  to  conceal  his  delusions  or  hallucinations.  It  has 
therefore  been  admitted  that  even  if  no  symptoms  of  disease  are 
apparent  and  if  a  superficial  examination  creates  no  suspicion 
of  mental  disorder,  an  investigation  should  be  instituted  to  dis- 
close any  latent  manifestations  of  such  disease.  If  mental  dis- 
ease so  far  developed  as  to  produce  delusions  and  false  accu- 
sations may  remain  unrevealed,  then  surely  it  must  also  be 
possible  for  individuals  in  apparent  mental  health  to  commit 
illegal  acts  as  a  result  of  a  pathological  disorder  of  thought, 
feeling  or  volition  which  must  be  regarded  as  a  product  of  dis- 
turbed freedom  of  determination.  Emphasis  would  therefore 
have  to  be  laid  upon  an  early  diagnosis.  The  existence  of  a 
psychosis,  or  the  disposition  to  its  formation,  would  have  to  be 
recognized  even  before  manifest  symptoms  had  developed. 
Koch's  investigations  concerning  psychopathically  inferior  in- 
dividuals, persons  who  develop  in  an  apparently  normal  man- 
ner for  years  and  then  break  down  under  the  stress  of  in- 
creased mental  demands,  were  conducted  with  this  end  in  view. 
Later  I  shall  show  that  such  individuals  require  special  care  by 
the  State  to  prevent  their  efficiency  and  powers  of  resistance 
from  being  too  severely  tried  in  the  struggle  for  existence.  An- 
other feature  of  value  in  forensic  psychiatry  has  been  the  dis- 
covery that  goiter,  nasopharyngeal  vegetations  and  other  ap- 
parently insignificant  bodily  abnormalities  may  constitute  the 
starting  point  for  psychic  disorder.  The  studies  of  Krafft- 
Ebing  and  Schrenck-Notzing  pertaining  to  the  causes  of  per- 
verted sexual  manifestations  have  made  many  unmoral  and 
legally  punishable  acts  receive  more  lenient  consideration.  Ade- 
quate proof  has  been  adduced  to  show  that  the  majority  of  such 
acts,  while  not  dependent  upon  a  pronounced  psychosis,  are 
nevertheless  based  upon  a  partial  disorder  of  mental  activity. 
Opinions  differ  as  to  how  this  "partial"  disorder  should  be 
interpreted.  Some  writers  use  this  term  to  convey  the  idea  that 
the  mental  life  of  the  individual  may  be  normal  in  one  direc- 
tion but  disordered  in  another.  The  majority,  however,  now 
favor  the  view  that  the  designation  "partial"  should  be  applied 
solely  to  the  degree  of  mental  disorder.  It  is  always  the  entire 
mental  life  that  is  pathologically  altered,  in  one  individual  to 


50   THE  UNSOUND  MIND  AND  THE  LAW 

a  smaller,  in  another  to  a  greater  degree.  Hence  the  word 
"partial"  when  used  in  this  connection  signifies  that  mental 
activity  is  diminished  in  all  directions,  while  the  word  "total" 
covers  cases  in  which  mental  activity  is  reduced  in  all  directions 
to  the  point  of  annulment  of  free  determination  and  of  respon- 
sibility. 

Finally,  the  recognition  that  hysteria  and  other  psycho- 
neuroses  may  develop  in  the  train  of  a  purely  psychic  trauma- 
tism (of  course  always  assuming  the  existence  of  a  diminished 
resistance  of  the  brain)  has  been  of  great  significance  in  foren- 
sic psychiatry. 

These  retrospective  considerations  should  not  be  brought  to 
an  end  without  mentioning  that  no  psychiatrist  has  done  so 
much  for  the  insane  person  who  comes  in  conflict  with  the  law 
as  has  Krafft-Ebing.  "Whatever  influence  modern  psychiatric 
studies  may  have  exerted  in  modifying  the  law 's  enactments  and 
their  judicial  interpretations  is  due  in  great  part  to  this  inves- 
tigator's endeavors.  But  his  expectation  that  the  near  future 
would  clear  up  our  understanding  of  certain  states  which  appear 
as  mere  moral  depravity  but  are  really  states  of  disease,  and 
that  subsequent  investigations  would  illuminate  our  apprecia- 
tion of  the  psychic  failings  that  bring  about  conditions  of  an- 
nulled freedom  of  determination,  have  not  yet  been  realized. 
Possibly  we  are  now  upon  the  threshold  of  a  great  advance. 

Quite  recently  psychiatry  has  gained  an  ally  in  sero-diagno- 
sis,  which  promises  to  enable  us  to  effect  an  early  differential 
diagnosis  and  to  detect  simulation  and  dissimulation.  For  years 
the  examination  of  the  blood  has  been  employed  in  psychiatry 
as  an  aid  to  diagnosis  and  prognosis.  But  I  have  satisfied  my- 
self from  innumerable  examinations  of  the  blood  of  insane  per- 
sons, extending  over  a  period  of  at  least  twenty  years,  that  no 
definite  conclusions  as  to  the  nature  of  the  existing  psychic 
disease  can  be  attained  from  the  blood  state  alone.  The  changes 
demonstrable  by  chemical  and  microscopic  or  spectroscopic  ex- 
amination of  the  blood  are  not  sufficiently  characteristic  to  make 
possible  the  recognition  of  a  definite  psychosis.  This  fact  has 
been  corroborated  by  other  investigations.  An  exception  must 
be  made  for  the  Wassermann  test  (complement  fixation)  whose 
value,  however,  is  a  restricted  one,  as  it  aids  us  only  in  recog- 
nizing the  psychoses  of  syphilitic  origin.     Very  recently,  how- 


HISTORICAL  RETROSPECT       51 

ever,  Abderhalden  of  Halle  has  given  us  a  method  which  prom- 
ises to  raise  the  examination  of  the  blood  to  a  most  important 
position  in  psychiatric  diagnosis.  He  starts  from  the  premise 
that  the  blood  rejects  all  foreign  or  disharmonious  substances 
and  accepts  only  such  matters  as  are  harmonious.  Under  nor- 
mal conditions  only  such  substances  are  transmitted  to  the  blood 
as  have  already  been  rendered  harmonious  by  the  process  of  di- 
gestion. But  it  may  happen  that  substances  not  disorganized, 
and  therefore  not  assimilable,  may  enter  the  blood  stream  di- 
rectly by  avoiding  the  gastro-intestinal  tract  (parenterally). 
The  blood  endeavors  to  rid  itself  of  these  foreign  bodies  (bac- 
teria, toxic  products  of  metabolism,  broken-down  tissue  cells, 
etc.)  through  the  formation  of  specific  defensive  ferments  whose 
office  it  is  to  transform  the  foreign  matter  into  harmonious  ele- 
ments. These  defensive  ferments  make  their  appearance  in  the 
blood  as  soon  as  foreign  cells  effect  an  entrance,  and  just  as 
these  cells  are  different  in  kind,  so  the  defensive  ferments  differ 
in  nature.  The  fact  that  such  defensive  ferments  occur  in  the 
blood  in  cases  of  psychic  disease  proves  the  dependence  of  psy- 
choses upon  bodily  alterations.  The  demonstration  of  the  ex- 
istence of  specific  defensive  ferments  in  the  blood  serum  enables 
us,  independently  of  all  clinical  symptoms  and  anatomical 
changes,  to  recognize  that  certain  organs  are  diseased  and  that 
their  breakdown  products  have  entered  the  circulation. 

Fauser  of  Stuttgart  was  probably  the  first  to  apply  these  tests 
in  mental  disorders,  and  his  discoveries  have  been  confirmed  by 
other  observers.  We  have  much  evidence  tending  to  show  that 
in  dementia  prgecox  breakdown  products  of  the  protein  of  the 
brain  cortex  and  of  the  genital  glands,  and  in  dementia  para- 
lytica breakdown  products  of  the  cortex  and  of  some  other  or- 
gans, are  present  in  the  circulation  and  give  rise  to  protective 
ferments  which  may  be  demonstrated  by  the  Abderhalden  meth- 
od, whereas  in  none  of  the  psychoses  and  neuroses  known  as 
"functional"  and  constitutional  can  the  presence  of  such  fer- 
ments be  demonstrated.  Time  will  tell  us  how  these  most  prom- 
ising studies  will  develop. 

Let  me  conclude  my  historical  introduction  by  expressing  the 
hope  that  the  modern  spirit  of  medical  scientific  investigation 
will  maintain  this  and  other  theories  in  a  state  of  activity,  and 
not  allow  them  to  become  anchored  by  means  of  dogmatic  atti- 


52       THE  UNSOUND  MIND  AND  THE  LAW 

tudes.  For  I  believe  I  have  shown  that  progress  in  the  growth 
of  psychiatry  is  possible  only  if  it  be  prevented  from  relapsing 
into  the  pernicious  system  of  attempting  to  prove  something 
by  means  of  preconceived  opinions  which  of  themselves  require 
proof.  Psychiatry  has  long  enough  allowed  itself  to  be  deceived 
by  captious  attempts  to  explain  the  causes  of  mental  activity 
and  disorder,  not  from  facts  gained  by  experience  but  from 
imagination  alone.  Observations  and  experiments  have  long 
enough  been  falsified  to  make  them  accord  with  seductive  the- 
ories. All  this  can  be  avoided  in  the  future,  but  only  if  psy- 
chiatry continues,  together  with  all  other  branches  of  medicine, 
an  unprejudiced  exact  natural  science  as  it  now  is. 


II 

t 

THE   NOTION   OF   MENTAL  DISORDER 

Even  a  century  ago  the  idea  that  disease  was  a  state  entirely 
different  from  that  of  health  was  widespread  among  physicians, 
as  well  as  among  people  in  general.  Disease  was  looked  upon, 
so  to  say,  as  a  hostile  agent,  and  not  infrequently  its  presence 
was  attributed  to  demonic  influence.  Virchow  was  the  first  to 
advocate  the  view  that  processes  of  disease  are  manifestations 
entirely  analogous  to  the  normal  processes  of  life,  differing 
from  them  only  in  degree.  Whether  the  organism  be  healthy 
or  sick,  respiration,  circulation,  metabolism  and  all  other  vital 
activities  are  governed  by  the  very  same  physical  and  chemical 
laws.  In  sickness  conditions  have  changed,  and  for  this  reason 
the  same  causes  produce  different  results.  It  is  because  condi- 
tions are  different  that  respiration  becomes  quicker  or  slower, 
metabolism  accelerated  or  retarded,  the  heart's  action  increased 
or  diminished,  etc.;  and  the  greater  the  change  in  condition, 
the  more  marked  do  these  alterations  in  vital  activity  become. 

There  does  not  exist  a  sharp  dividing  line  between  health 
and  disease.  Only  when  the  divergence  from  health  is  very 
pronounced  and  conditions  have  changed  abruptly,  as  is  the 
case  in  acute  poisoning  or  infectious  processes,  does  the  con- 
trast become  so  manifest  that  it  is  recognized  by  every  one  as  a 
state  of  disease.  Ordinarily,  however,  conditions  change  so 
gradually  and  health  passes  into  disease  so  imperceptibly  that, 
at  a  certain  period  of  the  transition,  even  the  experienced  phy- 
sician is  unable  to  determine  with  certainty  whether  the  per- 
son's state  of  health  is  still  normal  or  whether  it  has  already 
overstepped  the  bounds  of  the  pathological.  Because  the  change 
from  health  to  disease  usually  takes  place  in  every  individual 
by  intermediary  stages,  there  can  exist  no  gage  by  means  of 
which  we  can  accurately  distinguish  a  healthy  person  from  one 
who  is  sick.     This  is  true  especially  because  there  are  no  two 

53 


54   THE  UNSOUND  MIND  AND  THE  LAW 

individuals  who  accord  completely  in  the  conformation  of  their 
bodies  or  whose  vital  processes  functionate  in  precisely  the 
same  manner.  What  we  call  "normal"  is  by  no  means  a  fast 
and  inalterable  state,  but  a  notion  which  changes  within  widely 
varying  bounds.  We  know  that  the  adult  breathes  about  eight- 
een times  per  minute,  that  for  each  respiration  he  averages 
four  beats  of  the  heart,  that  the  temperature  of  the  human  body 
is  98.6  degrees  Fahrenheit,  that  one  cubic  centimeter  of  blood 
contains  about  five  million  red  blood  corpuscles,  etc.  But  we 
also  know  that  there  are  persons  in  whom  the  normal  pulse  rate 
is  fifty-five  while  in  others  it  is  eighty-five  beats  per  minute, 
and  likewise  that  individual  variations  from  the  average  meas- 
ures applying  to  other  so-called  normal  organs  are  known  to 
occur.  The  functions  of  the  body  cease  to  be  physiological  and 
become  pathological  only  when  they  are  discharged  in  excess, 
at  an  inappropriate  time  or  in  an  inappropriate  place.  There 
can  be  no  exact  boundary  line  between  the  physiological  and  the 
pathological.  In  a  general  way,  we  can  say  that  only  pronounced 
deviations  from  the  average  values  must  be  called  pathological. 
If,  for  instance,  we  assume  the  number  of  erythrocytes  per 
cubic  centimeter  of  blood  under  physiological  conditions  to 
vary  between  4,500,000  and  5,300,000,  then  a  single  blood  cor- 
puscle per  cubic  centimeter  below  or  above  these  limits  would 
theoretically  have  to  be  considered  abnormal.  The  absurdity 
of  making  one  blood  corpuscle  more  or  one  blood  corpuscle  less 
per  cubic  centimeter  a  measure  of  health  or  disease  is  self- 
evident. 

We  can  do  no  more  than  generalize  and  say  that  the  closer 
the  approach  of  the  functions  of  a  person's  organism  to  aver- 
age value,  the  nearer  he  is  to  a  state  of  health,  and  that  the 
more  these  functions  deviate  from  such  average  values,  the 
more  does  he  approach  a  condition  of  disease.  It  is  quite  as 
impossible  to  make  a  precise  distinction  between  healthy  and 
sick  individuals  as  it  is  to  divide  the  human  race  into  two  cate- 
gories, the  intelligent  and  the  stupid. 

The  "normal  type"  is  a  fiction  of  our  own  making.  Taking 
this  "normal  type"  as  representative  of  what  should  be,  and 
by  comparing  each  individual  with  this  fictitious  standard,  we 
are  able  to  differentiate  three  classes  of  human  beings,  viz. :  the 
unreservedly  healthy,  the  unreservedly   sick,   and   those  indi- 


THE  NOTION  OF  MENTAL  DISOEDER       55 

viduals  representing  the  numerous  intermediary  grades,  which, 
as  the  case  may  be,  are  nearer  to  health  or  nearer  to  disease. 
These  "borderline  states"  must  never  be  judged  by  individual 
symptoms.  It  is  entirely  unimportant  whether  there  are  pres- 
ent a  few  blood  corpuscles  more  or  a  few  blood  corpuscles  less, 
or  whether  the  pulse  beats  are  slightly  more  frequent  or  slightly 
less  frequent.  Such  symptoms  derive  their  significance  only 
from  their  relations  to  the  efficiency  of  the  entire  organism. 
A  scientist  not  accustomed  to  muscular  activity  may  be  healthy, 
notwithstanding  his  inability  to  lift  a  weight  of  one  hundred 
pounds,  while  a  laborer  unable  to  lift  such  a  weight  would 
have  to  be  considered  sick.  Not  every  deviation  from  the  nor- 
mal should  be  called  pathological,  but  the  individual  peculiari- 
ties must  in  every  instance  be  considered  before  judgment  can 
be  passed.  On  the  other  hand,  a  person  may  be  the  very  picture 
of  health,  may  subjectively  feel  perfectly  well,  and  may  never- 
theless be  afflicted  with  some  serious  organic  disease. 

Hence  we  must  recognize  the  important  fact  that  health  and 
disease  are  not  antithetical  but  represent  the  same  vital  proc- 
esses under  different  conditions.  Nature  distinguishes  no 
classes,  but  only  individuals,  each  one  of  whom  has  his  pe- 
culiarities and  no  one  of  whom  completely  resembles  another. 
Health  is  that  state  in  which  the  activities  of  life  are  equally 
balanced,  while  disease  is  a  disturbance  of  such  equilibrium, 
single  functions  preponderating  to  the  detriment  of  others. 
This  disturbance  may  set  in  abruptly  and  violently,  or  it  may 
develop  slowly  and  imperceptibly.  Where  the  resisting  pow- 
ers of  the  organism  are  adequate,  it  may,  notwithstanding  a 
stormy  course,  disappear  rapidly;  and  where  no  power  of  re- 
sistance exists,  it  may  lead  from  insignificant  beginnings  to 
permanent  functional  impairment.  It  may  affect  organs  of 
vital  importance  or  others  of  lesser  consequence.  What  is  of 
moment  and  decisive  in  all  these  grades  and  divisions  is  not 
the  individual  symptom  but  the  total  efficiency  of  the  organism. 
One  organism  will  adapt  itself  to  the  altered  conditions  with- 
out incurring  any  material  disorder  in  its  vital  activities;  an- 
other will  respond  to  comparatively  slight  changes  by  most 
severe  disturbances  of  function.  Thus  it  becomes  clear  how 
difficult  it  may  be  for  even  the  trained  expert  to  determine 
whether  a  certain  bodily  state  should  be  considered  normal  or 


56       THE  UNSOUND  MIND  AND  THE  LAW 

pathological,  or  to  decide  whether  it  occupies  a  borderline  be- 
tween health  and  disease. 

All  these  considerations  concerning  bodily  disease  may  be 
applied  without  change  to  the  conditions  obtaining  in  the  psychic 
domain.  Just  as  the  notion  of  bodily  disease  can  not  sharply  be 
defined,  it  is  impossible  to  give  a  precise  definition  of  mental 
disorder.  The  psychic  field,  like  the  physical  one,  consists  of 
individuals  and  not  of  classes  of  individuals  each  having  spe- 
cific characteristics.  Imperceptible  intermediary  stages  lead 
from  unquestionable  health  to  well-defined  mental  disease,  so 
that  it  is  often  very  difficult  to  determine  whether  a  person  is 
psychically  normal  or  psychopathic. 

This  difficulty  of  classifying  disorders  of  mental  activity  is 
even  greater  than  that  of  classifying  disturbances  of  bodily 
function,  for  notwithstanding  the  great  progress  made  by  neuro- 
pathology, it  is  as  yet  much  more  difficult  to  determine  the 
presence  of  anatomical  lesions  in  diseases  of  the  brain  and 
nervous  system  than  it  is  to  discover  them  in  pathological  alter- 
ations of  other  organs. 

For  the  present,  therefore,  modern  medicine  must  be  content 
with  the  notion  of  purely  "functional"  diseases,  disorders  not 
based  upon  any  structural  tissue  changes.  Theoretically  we 
must  admit  that  every  disturbance  of  health,  whether  of  psychic 
or  physical  nature,  is  dependent  upon  somatic  changes.  An 
organ  whose  structure  is  normal  will  functionate  normally,  and 
whenever  it  does  otherwise  some  structural  tissue  change  must 
exist.  This  does  not  signify,  however,  that  a  demonstrable 
alteration  in  structure  must  precede  every  change  of  func- 
tion. The  process  may  apparently  be  reversed  so  that  an  or- 
gan, for  instance  the  heart,  may  be  overworked,  and  then  can 
no  longer  functionate  in  a  normal  manner.  But  even  when  the 
functional  disturbance  has  preceded  the  anatomical  injury,  the 
principle  that  the  latter  constitutes  the  basis  for  the  former 
must  be  maintained.  Over-exertion  of  an  organ  carries  with  it 
an  immediate  alteration  of  tissue  structure,  which  is  followed 
by  an  alteration  in  function.  It  is,  therefore,  always  the  organic 
change  which  carries  the  functional  disturbance  in  its  train. 

With  our  present  methods  of  investigation,  we  are  very  fre- 
quently unable  to  demonstrate  these  organic  changes.  Conse- 
quently the  impression  may  be  conveyed  that  no  actual  disorder 


THE  NOTION  OF  MENTAL  DISORDER       57 

exists  but  that  one  is  being  simulated,  or  while  admitting  the 
existence  of  actual  disorder,  we  are  likely  to  conclude  it  can- 
not be  structural  but  must  be  of  purely  functional  nature.  If 
it  were  correct  to  assume  that  a  normal  organ  might  function- 
ate abnormally,  it  should  be  equally  correct  to  assume  that  an 
organ  which  is  pathologically  altered  may  functionate  normally. 
This  never  happens.  When,  for  instance,  a  valvular  heart 
lesion  becomes  compensated  through  hypertrophy  of  the  heart 
muscle,  this  does  not  mean  that  the  organic  change  has  become 
an  unimportant  factor  in  the  heart's  activity.  A  heart  thus 
affected  may  remain  efficient  for  many  years,  but  as  a  matter 
of  fact  it  does  not  functionate  normally  and  for  that  reason 
its  muscle  must  not  be  taxed  to  the  same  extent  as  that  of  a 
healthy  heart. 

From  the  foregoing  discussion,  it  is  clear  that  purely  func- 
tional disorders,  entirely  unrelated  to  any  alteration  of  tissue 
structure,  do  not  exist.  Every  functional  change  must  corre- 
spond to  some  organic  alteration,  or  vice  versa.  Even  such 
common  symptoms  as  headache  or  constipation  must  have  some 
material  basis.  Frequently  this  is  demonstrable  by  means  of 
the  physical  or  chemical  methods  of  examination  at  our  com- 
mand, or,  when  these  fail  us,  we  are  obliged  to  assume  that  the 
structural  changes  in  tissues  and  cells  are  so  infinitesimal  as  to 
be  undemonstrable  by  means  of  any  of  our  reagents,  instruments 
or  apparatus. 

Sometimes  the  functional  changes  are  essentially  due  to  dis- 
orders of  innervation — that  is  to  say,  the  organs  in  themselves 
are  healthy  but  receive  false  impulses  through  the  nerves  that 
regulate  their  activity.  In  other  cases,  nutritional  or  circula- 
tory disorders  may  be  present,  or  the  tissues  may  be  compressed 
by  a  pathological  increase  of  physiological  fluids  (for  instance, 
the  cerebrospinal  fluid),  or  the  vitality  of  the  cells  may  have 
been  diminished  by  the  resorption  of  toxic  metabolic  products. 
In  these  and  similar  instances  every  endeavor  to  demonstrate 
the  existence  of  anatomical  lesions  may  fail.  The  essential  point 
always  must  be  to  determine  the  extent  to  which  the  efficiency 
of  an  organism,  the  power  of  adapting  itself  to  the  extraordi- 
narily changeable  demands  of  life,  is  being  impaired  by  the 
existing  disorder  of  function.  We  now  know  that  mental  ac- 
tivity is  nothing  but  a  function  of  the  brain  cells  and  therefore 


58       THE  UNSOUND  MIND  AND  THE  LAW 

that  psychology  is  but  part  of  the  "physiology"  of  the  central 
nervous  system.  Notwithstanding  the  certainty  that  the  tissues 
of  the  brain  and  nervous  system  condition  all  mental  activity,  we 
are  seldom  able  to  demonstrate  the  material  basis,  the  struc- 
tural changes  in  the  tissues  of  the  brain  and  nervous  system, 
upon  which  disorders  of  mental  activity  depend.  Even  the 
autopsy  will  usually  reveal  only  those  structural  processes  and 
gross  brain  changes  which  are  characteristic,  for  instance,  of 
dementia  paralytica,  idiocy,  etc.  In  persons  who  for  years  have 
suffered  from  severe  neuroses  and  psychoses,  neither  during  life 
nor  in  death  are  we  able  to  find  any  evidences  of  tissue  changes 
that  would  explain  the  disorder  of  nerve  function.  This  usually 
normal  brain  finding  constitutes  one  of  the  greatest  obstacles  to 
a  clear  understanding  and  classification  of  mental  disorders. 
Needless  to  say,  this  brain  finding  is  only  apparently  a  normal 
one — as  a  matter  of  fact,  organic  changes  corresponding  to  the 
disorder  of  function  must  be  present,  but  we  have  not  been 
able  to  demonstrate  their  existence. 

While  it  is  certain  that  psychoses  have  their  material  basis, 
it  would  be  an  error  in  the  majority  of  instances  to  draw  any 
deductions  in  regard  to  the  degree  or  nature  of  an  insanity 
from  the  amount  of  tissue  changes  subsequently  found.  It  would 
be  equally  erroneous  for  us  to  rely  for  this  purpose  upon  single 
symptoms,  the  value  of  which,  after  all,  is  dependent  upon  the 
sum  of  the  individual's  peculiarities.  We  can  estimate  the 
gravity  of  a  mental  disorder  only  in  the  same  manner  as  we 
do  that  of  any  bodily  disease — that  is,  by  testing  the  extent  to 
which  defective  function  has  disturbed  the  equilibrium  of  vital 
activities.  But  while  our  conception  of  bodily  disease  will 
depend  upon  the  clinical  symptoms  combined  with  the  altera- 
tion of  tissue  structure,  our  conception  of  mental  disorder  as 
a  rule  will  have  to  be  based  upon  symptoms  alone. 

For  a  time  "degenerative  signs"  played  a  large  role  in 
forensic  psychiatry.  Certain  physical  anomalies  were  held  to 
indicate  the  existence  of  psychic  abnormalities.  Numerous  ob- 
servations have  shown,  however,  that  aside  from  an  abnormally 
small  skull,  which  of  course  must  contain  an  abnormally  small 
brain,  these  "degenerative  signs"  are  very  unreliable.  Such 
"stigmata"  may  be  present  in  persons  who  are  psychically  en- 
tirely healthy,  or  may  be  completely  absent  in  markedly  psy- 


THE  NOTION  OF  MENTAL  DISORDER       59 

chopathic  individuals.  We  shall  do  well,  therefore,  to  rely  as 
little  upon  any  "degenerative  signs"  that  may  be  found  as 
upon  the  structural  changes  of  the  brain  which,  although  they 
constitute  part  of  the  psychoses,  we  are  unfortunately  unable 
to  see. 

From  eccentricities  of  character  to  paranoia,  or  from  excited 
exhilaration  to  maniacal  furor,  the  distance  is  long  and  the  in- 
termediary steps  are  numerous.  Should  we  consider  every  per- 
son abnormal  whose  psychic  demeanor  differs  from  that  of  his 
companions?  Certainly  there  could  be  no  more  serious  error! 
In  the  psychic  domain  especially  it  is  not  a  question  of  individ- 
ual peculiarities  and  deviations,  but  of  the  entire  personality. 
A  mental  manifestation  which  in  one  individual  is  still  en- 
tirely normal,  in  another  may  be  very  suspicious.  The  methods 
of  people  in  expressing  their  feelings,  painful  or  joyous,  differ 
exceedingly.  Neither  exaggeration  nor  marked  repression  of 
feelings  of  pleasure  or  displeasure  is  in  itself  pathological.  A 
certain  degree  of  emotion  in  one  individual  may  be  pathological, 
while  the  same  degree  of  emotion  might  not  even  approximate 
another  person's  normal  average.  Normal  manifestations  often 
pass  most  gradually  into  mental  disease.  Not  infrequently  the 
depression  of  melancholia  is  based  upon  actual  occurrences. 
Normal  grief  concerning  a  serious  loss  or  a  great  misfortune 
may  constitute  its  beginning,  and  it  is  the  exaggeration  of  the 
emotion  that  finally  reveals  its  pathological  character.  But  at 
what  point  are  we  warranted  in  designating  the  emotion  as 
exaggerated?  Where  do  the  natural  expressions  of  pain  and 
joy  cease  to  be  normal?  Where  does  anxiety  begin  to  be  patho- 
logical? All  this  can  be  decided  only  by  a  study  of  the  par- 
ticular ease  and  by  carefully  considering,  in  connection  with 
other  individual  peculiarities,  how  far  the  total  psychic  accom- 
plishment has  deviated  from  its  average  efficiency.  Particularly 
in  education  has  the  neglect  of  individual  peculiarities  been 
the  cause  of  grievous  errors.  The  burden  forced  upon  society 
by  the  incompetents,  those  who  are  worthless  in  practical  life, 
is  often  due  only  to  errors  of  training.  The  older  pedagogy 
recognized  but  one  plan  of  instruction  and  training,  the  one 
adapted  to  average  capabilities,  and  took  no  cognizance  at  all 
of  individual  peculiarities.  Many  children  are  constituted  dif- 
ferently from  their  companions  of  equal  age,  but  they  must  not 


60       THE  UNSOUND  MIND  AND  THE  LAW 

be  considered  abnormal  for  that  reason  alone.  Because  chil- 
dren of  this  type  could  not  adapt  themselves  to  the  general 
mold,  the  older  pedagogy  regarded  them  as  incompetent  and 
worthless.  It  was  not  deemed  worth  while  to  lose  time  on  such 
children  or  to  study  their  mental  lives.  Not  infrequently,  to 
the  astonishment  of  every  one,  these  "peculiar"  individuals  in 
later  life  became  very  useful  and  sometimes  renowned  members 
of  human  society.  I  need  but  refer  to  Liebig,  who  was  considered 
a  ne'er-do-well  in  school,  and  for  whom  his  teacher  prophesied 
a  bad  ending.  His  instructor  did  not  surmise  that  the  genius 
of  a  natural  scientist  slumbered  within  him,  nor  were  the  pre- 
vailing methods  of  training  calculated  to  bring  to  light  the  en- 
dowment he  possessed.  Had  Liebig  not  accidentally  come  into 
surroundings  which  favored  the  development  of  his  undiscov- 
ered talent,  he  never  would  have  attained  eminence  as  a  chem- 
ist. By  way  of  contrast,  it  should  be  noted  that  so-called  model 
pupils,  who  have  conformed  in  every  way  to  the  school  regula- 
tions, often  fail  to  gain  even  average  success  in  later  life.  Model 
pupils  are  not  necessarily  distinguished  by  unusual  endowment. 
Children  with  more  than  ordinary  capabilities  are  usually  the< 
ones  whose  nature  will  rebel  against  the  restraint  of  a  system 
of  instruction  modeled  according  to  a  preconceived  plan.  The 
more  marked  a  pupil's  individuality,  the  greater  the  difficulty  he 
will  experience  in  adapting  himself  to  a  predetermined  mold. 
Conversely,  the  less  pronounced  the  individuality,  the  more  easily 
will  such  adaptation  be  accomplished.  Model  pupils  are  often 
the  very  ones  whose  intelligence  is  only  just  sufficient  to  meet 
the  demands  of  the  school;  and  any  talent  they  may  possess 
becomes  dwarfed  through  lack  of  opportunity  for  growth,  unless 
perchance  that  talent  happens  to  come  within  the  scope  of  the 
instructional  plan. 

More  often  we  will  find  that  children  without  any  talent  what- 
soever will  exert  themselves  beyond  their  capabilities.  In  order 
to  keep  pace  with  their  companions  they  will  fulfil  all  their 
obligations,  allow  themselves  no  recuperation,  and  even  sacrifice 
their  rest  at  night.  For  such  children,  the  school's  demands, 
which  can  be  met  without  difficulty  by  the  child  of  ordinary 
capabilities,  will  represent  an  overtaxation  which  causes  suffer- 
ing or  a  breakdown,  and  notwithstanding  their  apparently  nor- 


THE  NOTION  OF  MENTAL  DISORDER       61 

mal  efficiency  in  school,  they  will  become  "unfit"  to  withstand 
the  struggle  for  existence. 

Forensic  psychiatry  is  frequently  called  upon  to  pass  judg- 
ment upon  individuals  whose  conflict  with  the  law  is  essen- 
tially attributable  to  misdirected  education.  As  a  rule  this  prob- 
lem is  encountered  in  cases  of  juvenile  delinquents  who,  when 
at  school,  did  not  fit  into  the  general  schedule.  Either  they 
rebelled  against  restraint,  or  they  learned  nothing  because  the 
method  of  instruction  made  no  allowance  for  their  individu- 
ality, or  permanent  injury  to  the  nervous  system  was  caused  by 
the  overstrain  to  which  it  was  subjected.  So  long  as  persons 
subject  to  such  misfortunes  remain  guarded  and  protected 
against  the  stress  of  stern  reality,  their  deficiencies  may  remain 
almost  or  entirely  unrevealed  and  their  life  may  be  peaceful. 
But  as  soon  as  they  are  obliged  to  depend  upon  their  own  re- 
sources, to  provide  for  their  own  existence,  they  encounter  de- 
mands for  which  they  are  unadapted.  Being  unable  to  suc- 
ceed against  efficient  competitors,  they  cannot  find  permanent 
occupation,  they  sooner  or  later  encounter  want  and  misery,  and 
thus  enter  upon  a  downward  path  which  not  infrequently  leads 
to  transgression  of  the  law. 

In  many  cases  such  unfortunate  occurrences  could  have  been 
avoided  by  proper  education.  The  manner  in  which  experi- 
mental psychology  has  enabled  the  teacher  to  recognize  and  to 
treat  the  individuality  of  his  pupils  has  been  explained  in  my 
book  on  "Child  Training."  At  this  place  I  would  merely  indi- 
cate that  it  is  not  the  lack  of  space  in  the  world  for  persons  of 
strong  individuality  that  brings  about  conflicts  with  the  law. 
Almost  every  person  has  an  individual  natural  disposition  by 
means  of  which  he  can  be  of  service  to  those  about  him;  every 
capability  fades  and  dies  when  not  developed  by  use;  the  art 
of  training  must  not  confine  itself  to  the  development  of  pro- 
nounced talents,  but  must  endeavor  to  discover  and  cultivate 
the  hidden  natural  qualities  which  every  person  possesses.  No 
matter  how  much  a  person  may  deviate  from  the  average,  no 
matter  how  backward  he  may  be  in  mental  efficiency,  he  will 
usually  be  found  to  possess  some  quality  that  may  be  utilized 
in  an  active  serviceable  manner.  The  man  who  is  able  properly 
to  wield  an  ax  and  a  shovel  is  of  far  greater  cultural  value 
than  the  educated  idler.    There  is  room  in  the  world  for  every 


62       THE  UNSOUND  MIND  AND  THE  LAW 

individual  capable  of  doing  useful  work.  Conflict  and  struggle 
are  due  essentially  to  the  fact  that  many  persons  follow  pur- 
suits for  which  they  are  not  adapted.  Through  erroneous  train- 
ing they  are  forced  into  paths  which  run  contrary  to  their 
nature  and  which  give  to  their  lives  an  entirely  false  direction. 
Thus  it  may  well  occur  that  a  person  on  the  boundary  line 
between  mental  health  and  disease  may  gradually  become  pro- 
nouncedly psychopathic,  while  early  recognition  of  his  indi- 
vidual peculiarities  would  have  protected  him  from  many  de- 
viations. It  is  always  the  "borderline  cases"  that  are  so  hard 
to  recognize,  and  not  the  easily  determinable  psychoses,  that 
lead  to  the  serious  and  irremediable  errors  so  readily  committed 
by  indiscriminating  pedagogy. 

But  in  the  domain  of  jurisprudence,  too,  the  disregard  of  in- 
dividual peculiarities  has  often  caused  the  most  dire  error;  and 
this  applies  more  particularly  to  those  Anglo-Saxon  countries 
whose  statutes  are  still  based  upon  the  assumption  that  a  person 
is  either  mentally  healthy  and  entirely  responsible,  or  else 
insane  and  entirely  irresponsible.  That  between  these  two  ex- 
tremes there  exist  gradations,  each  characterized  by  a  greater  or 
lesser  restriction  of  free  determination  of  the  will  and  respon- 
sibility, is  a  fact  which  has  not  yet  been  recognized  to  any  ex- 
tent by  Anglo-Saxon  jurisprudence.  Even  when  it  has  been 
demonstrated  that  a  particular  case  is  one  occupying  the  bor- 
derline, being  neither  normal  nor  distinctly  pathological  and 
in  which  therefore  responsibility  must  be  assumed  to  be  atten- 
uated, a  judge  under  existing  laws  will  be  placed  in  the  diffi- 
cult position  of  having  to  decide  either  for  mental  health  and 
entire  responsibility  or  for  insanity  and  total  irresponsibility. 
In  the  first  instance  the  decision  would  be  too  lenient,  in  the 
latter  too  severe,  and  yet  it  might  have  to  be  given  against  the 
judge's  moral  conviction.  The  difficulties  of  the  question  are 
enhanced  by  an  almost  insuperable  general  prejudice  which 
insists  that  because  an  accused  person  apparently  reasons  logi- 
cally and  acts  with  premeditation  he  can  not  be  insane.  Under 
the  circumstances  many  a  person  with  marked  mental  defects 
will  be  considered  healthy,  while  others  without  any  mental 
defect,  but  merely  constituted  differently  from  the  majority, 
will  be  considered  insane. 

From  what  we  have  said,  it  should  be  clear  that  the  notion 


THE  NOTION  OF  MENTAL  DISORDEE       63 

of  mental  disease  cannot  be  definitely  restricted  but  must  be 
extended  so  as  to  give  due  consideration  to  those  numerous 
transitional  states  which  at  present  have  no  significance  from 
the  layman's  viewpoint. 


Ill 

PSYCHOPATHIC   DISPOSITION 

The  preceding  chapter  has  shown  us  that  there  exists  a 
parallelism  between  all  bodily  and  mental  manifestations  of 
life.  The  notion  of  sickness,  whether  in  the  physical  or  psychic 
domain,  cannot  be  strictly  circumscribed  and  the  boundary  line 
between  health  and  disease  is  always  inconstant.  Whether  a 
particular  person  is  healthy  or  sick  cannot  be  established  by  a 
comparison  with  a  "normal  type,"  but  only  when  considered 
in  connection  with  his  own  general  capability.  We  cannot  esti- 
mate the  seriousness  of  a  disease  from  the  extent  of  the  ana- 
tomical lesion  involved,  because  in  many  instances,  though  more 
often  in  mental  than  in  physical  disorder,  no  deviation  from 
the  normal  can  be  recognized  in  the  structure  of  the  tissues. 
Nor  can  we  draw  any  conclusions  regarding  the  gravity  of  a 
disease  from  the  intensiveness  of  the  subjective  complaints,  since, 
for  example,  so  harmless  an  affection  as  toothache  may  cause 
the  utmost  pain,  while,  on  the  other  hand,  diabetes,  chronic 
nephritis,  dementia  paralytica  and  other  serious  diseases  fre- 
quently produce  but  little  subjective  disturbance. 

Our  main  consideration  should  be  to  determine  to  what  ex- 
tent the  efficiency  of  the  organism  has  been  disturbed  by  the 
disordered  function.  It  would  be  going  too  far  to  say  that 
every  grown  person  must  be  able  to  lift  a  weight  of  one  hun- 
dred pounds  to  a  certain  height  in  a  certain  length  of  time; 
or  that  unless  a  person  of  normal  intelligence  is  able  to  under- 
stand the  Darwinian  theory,  he  is  deficient.  On  the  other 
hand,  if  a  man  who  has  always  been  able  to  lift  a  one-hundred- 
pound  weight  from  the  floor  to  the  table  suddenly  loses  power 
to  do  so,  we  may  designate  him  as  sick;  or  we  may  designate  a 
brain  as  diseased  if,  after  having  been  able  to  solve  the  most 
intricate  problems,  it  suddenly  becomes  incapable  of  compre- 
hending the  simplest  matters. 

In  a  determination  of  disorder  of  function,  the  question  is 

64 


PSYCHOPATHIC  DISPOSITION  65 

essentially  one  of  the  extent  to  which  efficiency  has  been  re- 
duced, as  compared  with  its  former  self.  Such  a  test  is  of  value 
only  when  we  consider  whether  the  task  demanded  of  a  person 
is  one  which  is  adapted  to  his  individuality.  We  should  always 
bear  in  mind  the  fact  that  many  persons  fail  only  because 
their  conditions  of  life  are  unfavorable  ones  and  they  are 
obliged  to  carry  on  an  occupation  repugnant  to  their  proper 
personality,  while  under  favoring  circumstances  they  would 
have  been  perfectly  able  to  fill  their  places  in  society.  These 
governing  principles,  the  guides  of  modern  pathology  and  psy- 
chopathology,  should  be  indelibly  graven  upon  the  memory 
of  both  physician  and  jurist. 

Ordinarily,  two  factors  are  essential  for  the  causation  of  dis- 
ease :  First,  a  pathogenous  cause,  and,  second,  a  predisposition 
to  disease.  In  exceptional  cases  a  pathogenous  cause  (for  in- 
stance, a  potent  poison)  is  sufficient  in  itself  to  produce  disease 
or  even  death.  But  even  in  such  cases,  the  individual  resist- 
ability  plays  a  part,  for  although  conditions  may  otherwise  be 
similar,  one  individual  will  become  more  easily  affected  by  the 
disease-producing  agency,  or  will  succumb  sooner  to  its  action, 
than  another.  On  the  other  hand,  predisposition  alone  never 
produces  disease.  In  fact,  in  favorable  environment  predispo- 
sition may  remain  latent  throughout  a  person's  entire  life. 
Ordinarily,  however,  as  every  person  is  obliged  at  some  time  or 
other  to  assume  obligations  which  require  more  or  less  effort, 
and  which  then  may  constitute  conditions  unfavorable  to  him, 
a  predisposition  to  disease  rarely  remains  concealed  for  any 
protracted  length  of  time.  The  fact  that  different  individuals 
react  differently  to  serious  injuries  can  be  understood  only  when 
it  is  assumed  that  the  powers  of  resistance  and  the  adaptability 
to  altered  conditions  of  life  vary  in  different  persons. 

To  a  certain  extent  man  possesses  the  capability  of  equalizing 
alterations  in  his  conditions  of  life  by  changes  in  his  vital  ac- 
tivity. "Were  this  not  so,  there  could  be  no  healthy  persons,  for 
in  consequence  of  change  in  climate,  food,  work,  etc.,  our  con- 
ditions of  life  are  constantly  varying.  This  power  of  adapta- 
tion, however,  is  possible  only  within  certain  definite  limits. 
Once  those  limits  are  passed,  the  organism  responds  to  variations 
in  its  conditions  of  life  by  pathologic  disturbances.  The  re- 
sisting power  of  an  individual  is  another  expression  for  the 


66       THE  UNSOUND  MIND  AND  THE  LAW 

limits  within  which  variations  in  his  conditions  of  existence  may 
take  place  without  disturbing  the  normal  processes  of  life. 
"When  the  power  of  resistance  is  so  reduced  that  very  slight 
injuries  are  sufficient  to  disarrange  the  balance  of  vital  activity, 
we  speak  of  a  predisposition  to  disease;  where  the  disarrange- 
ment is  one  of  psychic  activity,  we  speak  of  psychopathic  taint. 

A  predisposition  to  disease  is  of  decisive  significance  not 
only  in  relation  to  the  production  of  a  disease  but  also  to  its 
course.  A  strong  and  virile  organism  actively  defends  itself, 
the  feeble  one  remains  passive.  But  we  must  not,  as  was  for- 
merly done,  consider  the  predisposition  to  disease  a  fixed  and 
unalterable  element,  always  dependent  upon  congenital  pe- 
culiarities. On  the  contrary,  it  is  a  variable  factor  which  can 
be  better  understood  only  by  subdividing  it  into  its  various 
parts.  "When  we  attempt  to  do  this  we  again  learn  that  the 
altered  states  which  we  call  disposition  to  disease  can  be  meas- 
ured as  little  by  unyielding  formulae  and  rules  as  can  the  con- 
cepts of  health  and  disease.  Each  must  receive  entirely  indi- 
vidual consideration.  Disposition  to  disease  must  be  divided 
into  that  which  is  congenital  and  that  which  is  acquired.  Fre- 
quently the  idea  of  congenital  disposition  is  confounded  with 
that  of  hereditary  taint.  It  is  only  possible  to  inherit  some- 
thing which  has  existed  in  the  ancestors.  A  disposition  to  dis- 
ease, however,  may  be  congenital  although  not  a  trace  of  it  is 
discoverable  in  the  ancestral  tree.  In  fact,  a  child  may  come 
into  the  world  not  only  with  a  disposition  to  disease  but  with 
a  disease  already  developed,  and  we  may  not  be  able  to  trace  this 
disease  in  its  parents  or  other  forebears.  In  such  a  case  the 
predisposition,  or  the  disease  itself,  is  dependent  upon  injuries 
which  have  taken  place  during  intrauterine  development  or 
during  the  act  of  parturition.  Inherited  predisposition  to  dis- 
ease is  therefore  always  congenital,  while  congenital  predis- 
position is  not  necessarily  inherited.  The  point  to  decide  is 
whether  the  germ  plasm  was  already  damaged  at  the  time  of 
procreation  or  whether  the  damage  took  place  only  after  im- 
pregnation. 

I  would  also  emphasize  the  statement  that  the  phrase  "dispo- 
sition to  disease"  relates  not  to  evident  organic  changes  but  to 
diminished  resistibility.  For  example,  in  the  case  of  a  child 
born   with  clearly  pronounced  syphilitic  disorder,  or  with  an 


PSYCHOPATHIC  DISPOSITION  67 

abnormally  small  skull  and  brain,  there  can  be  no  question  of  a 
predisposition,  but  the  child  must  actually  be  considered  as 
afflicted  with  congenital  disease.  Nevertheless,  I  admit  that 
just  as  it  is  impossible  to  draw  a  sharp  dividing  line  between 
health  and  disease,  so  between  predisposition  to  a  disease  and 
the  disease  itself  no  sharp  line  of  demarkation  can  be  drawn — 
a  fact  which  is  clearly  exemplified  in  many  diseases  of  the 
brain  and  nervous  system  in  which  the  predisposition  passes 
over  without  discoverable  organic  changes  into  disease  itself. 

Predisposition  to  disease  may  therefore  be  defined  as  a  rela- 
tive weakness  of  the  constitution  of  the  body,  which  enhances 
the  susceptibility  of  the  entire  organism  to  disease-producing 
agencies.  The  disposition  itself  may  remain  entirely  within 
normal  confines,  so  that  under  favorable  conditions  the  indi- 
vidual may  remain  healthy  throughout  his  entire  life.  The 
disposition  to  disease  acquires  its  pathological  stamp  only  when 
the  ordinary  stimuli  against  which  the  normal  organism  should 
be  prepared  are  already  capable  of  causing  disease.  The  trans- 
mitted weakness  may  involve  a  particular  organ,  as  for  in- 
stance the  brain,  or  it  may  extend  to  the  entire  constitution ;  for 
this  reason  a  disease  which  has  been  present  in  the  ascendants 
need  not  appear  in  the  descendants,  although  all  of  these  may 
have  inherited  their  ancestor's  predisposition. 

The  disposition  to  disease  plays  an  important  role  not  only 
in  many  anomalies  of  metabolism  (obesity,  diabetes,  etc.)  and 
infectious  processes  (tuberculosis,  etc.)  but  also  in  nervous  and 
mental  diseases.  Man's  brain,  like  the  rest  of  his  organs,  pos- 
sesses a  certain  average  efficiency  in  order  that  he  may  meet  the 
ordinary  demands,  but  in  addition  it  possesses  a  certain  amount 
of  reserve  force  for  use  under  exceptional  conditions.  Some 
individuals  may  persistently  make  the  greatest  demands  upon 
their  central  nervous  system,  may  even  commit  great  ex- 
cesses without  in  any  way  sacrificing  their  mental  efficiency. 
They  appear  to  be  immune.  Others  again — and  these  constitute 
the  majority — become  markedly  fatigued  through  brain  work. 
If,  at  the  same  time,  they  are  psychopathically  predisposed,  a 
few  emotional  shocks  will  often  suffice  to  upset  their  mental 
equilibrium.  We  must  therefore  differentiate  between  two  main 
types  of  cases:  First,  those  in  which  there  exists  from  birth 
merely  a  predisposition  to  disease,  and  in  which  disease  itself 


68       THE  UNSOUND  MIND  AND  THE  LAW 

develops  only  under  the  influence  of  other  injuries  which  a 
more  robust  constitution  would  have  withstood ;  and  second, 
those  in  which  not  only  the  disposition  to  disease,  but  also 
pathological  alterations,  have  existed  from  or  before  birth,  and 
in  which  disease  develops  without  the  aid  of  any  exogenous 
cause.  Between  these  two  main  classes  there  are  numerous 
transitional  and  mixed  forms. 

When  the  disposition  to  disease  is  an  inherited  one,  two  con- 
ditions, as  already  indicated,  must  coexist:  First,  one  of  the 
ancestors  must  have  had  the  same  disease  or  a  predisposition 
to  its  development ;  and  second,  the  transmission  to  the  descend- 
ant must  have  taken  place  through  the  parental  germ  plasm. 

We  can  see,  therefore,  that  the  existence  of  inherited  predis- 
position cannot  be  determined  merely  because  the  particular  dis- 
ease is  present  in  both  parent  and  child.  A  disposition  to  dis- 
ease may  be  congenital  and  may  have  been  transmitted  through 
the  parental  germ  plasm,  and  yet  there  may  be  no  question  of 
heredity.  For  instance,  if  the  descendants  of  an  insane  alco- 
holic have  a  congenital  predisposition  to  mental  disease,  this 
predisposition  would  not  necessarily  be  an  inherited  one,  in 
case  the  progenitor  himself  had  no  such  predisposition  but  had 
acquired  his  insanity  as  a  result  of  his  alcoholic  excesses.  In 
this  example  the  origin  in  the  descendants  of  the  predisposition 
to  mental  disease  can  be  comparatively  easily  explained.  The 
abuse  of  alcohol  caused  a  poisoning  not  only  of  the  brain  cells 
but  of  the  other  germ  cells  as  well,  and  as  a  result  the  tissues 
and  organs  which  they  produced  became  inferior  and  less 
resistant. 

According  to  Lubarsch  the  foregoing  process  is  analogous  to 
that  which  obtains  in  the  disposition  to  phthisis,  so  often  found 
in  the  descendants  of  tuberculous  parents,  even  when  the  latter 
had  originally  not  been  predisposed  to  tuberculosis.  The  germ 
cells  of  the  parents  become  damaged  by  the  poisons  that  have 
been  generated  by  the  tubercle  bacilli,  with  the  result  that  the 
children  are  weak  and  consequently  more  susceptible  to  a  tu- 
berculous infection.  We  must  assume  that  the  material  that 
constitutes  the  germ  cell  is  not  entirely  uniform  throughout,  but 
is  differentiated  according  to  the  various  organs  or  tissues  for 
whose  formation  it  is  destined;  and  that  the  individual  parts 
of  the  cell,  even  in  their  undeveloped  state,  possess  a  varying 


PSYCHOPATHIC  DISPOSITION  69 

receptivity  for  the  poisons  which  act  upon  the  entire  germ 
plasm.  Hence  we  can  understand  why  the  offspring  of  an  in- 
sane alcoholic  possesses  an  unresisting  brain;  and  why  the  off- 
spring of  tuberculous  parents  are  constitutionally  susceptible  to 
tuberculosis  or  are  deficient  in  some  other  way.  It  seems  to  me 
to  be  quite  as  comprehensible  that  damage  to  the  germ,  whether 
due  to  the  father  or  the  mother  or  to  both,  whether  occurring 
during  the  act  of  procreation,  or  subsequently  through  the  pla- 
cental circulation,  will  in  some  cases  inhibit  the  development  of 
certain  organs  only,  and  in  others  will  involve  the  entire  con- 
stitution. On  the  other  hand,  it  is  difficult,  if  not  entirely  im- 
possible, satisfactorily  to  explain  why  bodily  and  mental  pe- 
culiarities are  transmitted  through  entire  generations,  and 
why  this  transmission  should  always  be  conditioned  upon  two 
cells  only  microscopically  recognizable,  the  egg  cell  and  the  sperm 
cell.  Our  comprehension  of  this  phenomenon  is  still  further 
obscured  by  the  fact  that  influences  affecting  all  the  numerous 
and  complicated  bodily  and  mental  dispositions  are  crowded  to- 
gether into  so  small  a  space. 

It  is  just  as  difficult  to  understand  why  inherited  qualities 
appear  for  a  certain  time  in  an  ancestral  tree  and  then  seem 
to  vanish  only  to  reappear  later.  Certain  dispositions  to  dis- 
ease often  skip  several  generations  before  they  again  assert 
themselves.  This  happens  even  when  the  condition  of  life  for 
all  the  generations  involved  has  apparently  remained  unaltered. 
Why  does  the  disposition  to  disease  remain  ''latent"  in  the  one 
instance  and  develop  in  the  other?  The  only  answer  that  can 
be  given  to  this  question  is  that,  after  all,  the  conditions  of 
life  must  have  become  changed.  This  remarkable  empirical  fact, 
moreover,  applies  not  only  to  the  hereditary  transmission  of 
pathological  qualities  but  also  to  the  transmission  of  service- 
able qualities.  Scholz  believes  the  entire  world  would  be  a  home 
for  chronic  invalids  if  only  the  degenerative  ones  could  be  hered- 
itarily transmitted.  Hence  it  would  appear  that  a  balance  is 
maintained  which  prevents  a  too  extensive  degeneration  of  the 
human  race. 

Upon  the  basis  of  the  laws  of  heredity  as  studied  upon  plants 
by  Johann  Gregor  Mendel,  and  as  a  result  of  the  application  of 
his  methods  by  others  to  determine  the  laws  of  heredity  among 
animals,  we  know  it  is  not  chance  but  a  law  of  nature  which 


70       THE  UNSOUND  MIND  AND  THE  LAW 

causes  any  particular  quality  to  remain  constant  in  certain 
species,  and  which  causes  certain  qualities  at  one  time  to  ap- 
pear, and  at  another  to  disappear. 

The  application  of  the  Mendelian  law  to  human  heredity  and 
development  of  physical  traits  necessarily  followed,  and  it  is 
now  in  the  highest  degree  probable  that  the  hereditary  trans- 
mission of  psychic  properties  will  also  be  best  understood  in  the 
light  of  this  law.  Whether  it  can  purposely  be  utilized,  how- 
ever, to  eradicate  degenerative  qualities  and  to  cultivate  regener- 
ative ones  by  proper  selection  of  the  germ  cells  during  the  copu- 
lative act  is  a  question  which  cannot  even  approximately  be 
determined. 

A  psychopathic  taint  is  not  necessarily  always  congenital  or 
inherited,  but  may  be  acquired  in  later  life.  In  such  cases  it 
is  dependent  upon  the  weakening  of  psychic  energy,  which  so 
often  is  found  to  follow  exhausting  disease.  While  there  are 
infectious  processes  which  render  the  person  who  has  withstood 
them  for  a  long  time  immune  to  infectious  germs  of  the  same 
kind  and  more  resistant  generally,  it  is  also  true  that  recovery 
from  those  infections  is  often  accompanied  by  a  diminished  re- 
sistibility  of  the  brain. 

The  intrinsic  noxious  influences  (syphilis,  alcoholism,  mor- 
phinism, etc.)  which  produce  psychoses  even  when  no  congeni- 
tal or  acquired  psychopathic  taint  exists,  must  be  considered 
separately,  and  will  receive  attention  in  the  following  chapter. 
It  is  worth  referring  to  them  at  this  place  merely  because  the 
predisposition  to  disease  and  the  consequent  increasing  suscepti- 
bility to  the  influence  of  pathogenic  influences  produce  a  soil 
most  favorable  to  the  growth  of  neuroses  and  psychoses.  In 
such  cases  the  central  nervous  system  is  the  locus  minoris 
resistenticB. 

The  question  whether  an  acquired  disposition  to  disease  may 
be  hereditarily  transmitted  is  one  closely  allied  to  that  of  the 
possibility  of  the  hereditary  transmission  of  acquired  peculiar- 
ities. Some  investigators,  for  instance  Weissmann,  positively 
deny  that  this  can  happen.  But  if  it  be  true  that  a  constitu- 
tional anomaly,  a  "habitus,"  alone  can  be  transmitted,  then  we 
cannot  understand  how  this  habitus  could  have  originated  in 
the  first  place.  Scholz  characterizes  the  constitutional  anomaly 
as  the  persisting  property  which  has  become  an  essential  part 


PSYCHOPATHIC  DISPOSITION  71 

of  the  individual,  while  he  calls  abnormality  an  accidental  tran- 
sitory property.  But  at  what  point  do  abnormality  and  anomaly 
separate?  At  one  time  or  another  the  anomaly  must  have  been 
acquired.  Some  one  generation  must  have  had  impressed  upon 
it  some  morbid  peculiarity  which  preceding  generations  did  not 
have ;  and  if  these  abnormalities  could  not  be  transmitted  to  the 
descendants  they  could  never  have  become  stable,  could  never 
have  become  a  permanent  part  of  the  constitution,  could  never 
have  become  an  anomaly. 

That  acquired  qualities  can  be  hereditarily  transmitted  seems 
to  be  proved  by  the  comportment  of  our  immigrants.  They  bring 
with  them  qualities  which  were  serviceable  ones  in  their  old 
homes  but  for  which  in  their  new  place  of  abode  they  have  no 
use.  Under  the  influence  of  the  foreign  surroundings  these 
qualities  are  gradually  cast  off  and  new  ones  are  acquired  by 
means  of  which  the  individuals  adapt  themselves  to  the  altered 
conditions  of  life.  These  newly  acquired  qualities  usually  be- 
come stable  in  the  second  or  third  generation,  a  proof  that  they 
have  become  hereditarily  transmitted.  But  what  is  true  of 
normal  qualities  must  also  be  possible  for  pathological  ones.  Of 
course  mutilation  resulting  from  injury,  as  for  instance  the  loss 
of  an  extremity,  cannot  be  hereditarily  transmitted  to  one's  de- 
scendants. For  that  reason,  notwithstanding  all  his  exact  lab- 
oratory experiments,  Weissmann  was  never  able  to  produce  a 
tailless  species  of  mice  by  cutting  off  the  tails  of  many  genera- 
tions of  new-born  mice  before  allowing  them  to  breed.  But  from 
the  examples  of  the  insane  alcoholic  and  the  tuberculous  indi- 
viduals, mentioned  above,  it  must  be  evident  that  previously 
healthy  individuals  who  have  acquired  certain  peculiarities 
through  disease  can  transmit  those  peculiarities  to  their  off- 
spring. 

In  this  connection  the  experiments  of  Stockard  are  peculiarly 
interesting.  In  his  studies  of  the  effects  of  alcohol  upon  hered- 
ity he  has  been  able  to  show  that  the  inhalation  of  the  fumes 
of  alcohol  can  so  injure  the  male  germ  cells  that  even  in  mating 
with  strong  unalcoholized  females  the  offspring  will  be  defect- 
ive. Moreover,  he  has  shown  that  these  offspring,  upon  reaching 
maturity,  are  usually  nervous  and  slightly  undersized,  and  that 
the  injury  of  the  germ  cells  is  not  only  manifest  in  the  imme- 
diate offspring  but  also  in  their  descendants  for  at  least  three 


72       THE  UNSOUND  MIND  AND  THE  LAW 

generations.  In  one  instance  two  of  four  young  guinea  pigs 
were  completely  ej^eless,  the  eyeballs,  the  optic  nerves  and 
chiasm  being  absent,  and  neither  the  parents  nor  the  four  grand- 
parents but  only  the  great  grandfathers  and  not  the  great 
grandmothers  had  been  subjected  to  alcoholization. 

In  my  opinion  the  decisive  point  is  whether  the  acquired 
peculiarity  has  become  part  of  the  person's  nature,  so  that  the 
germ  cells  also  have  become  influenced  by  it.  This,  for  instance, 
would  not  be  the  ease  in  the  event  of  single  alcoholic  excesses 
but  would  be  so  in  chronic  alcoholism;  it  would  not  be  so  in 
acute  disease  but  would  be  so  in  a  chronic  decline.  But  that 
acquired  peculiarities  may  become  habitual  in  a  few  years,  and 
therefore  that  it  would  by  no  means  require  generations  in  order 
to  transform  an  abnormality  into  an  anomaly,  is  shown  by  the 
fact  that  peculiarities  accidentally  acquired  often  alter  a  per- 
son's entire  individuality. 


IV 

EXOGENOUS    CAUSES    OF    MENTAL    DISEASE 

The  layman  as  a  rule  believes  the  exogenous  causes  of  in- 
sanity to  be  those  happenings  which  have  immediately  preceded 
the  onset  of  the  mental  disorder.  Yet  we  know  the  mental  dis- 
order would  not  have  become  manifest  had  the  brain  not  been  a 
deficient  one,  either  from  birth  or  for  a  long  time  preceding  the 
outbreak.  In  general  it  may  be  said  that  psychic  shock  or  bodily 
disorder  of  itself  will  not  produce  insanity.  Every  mental 
disorder  requires  for  its  production  a  reciprocal  influence,  which 
in  the  majority  of  instances  consists  in  a  cooperation  of  various 
factors.  According  to  the  existing  degree  of  hereditary  taint, 
the  brain  will  become  more  or  less  seriously  damaged  by  equiva- 
lent extrinsic  causes.  In  other  words,  a  markedly  deficient 
brain  will  lose  its  balance  in  consequence  of  very  slight  causes, 
while  a  more  robust  central  nervous  system  will  easily  resist 
these  same  influences  and  will  break  down  only  under  great 
pressure. 

Just  as  there  is  no  absolute  immunity  to  physical  disease, 
so  there  can  be  none  to  mental  disorder.  Just  as  there  are  in- 
fections and  toxic  influences  to  which  even  the  healthiest  organ- 
ism must  succumb,  so  it  is  possible  for  a  person  without  a  trace 
of  inherited  taint  to  become  mentally  diseased.  In  such  in- 
stance, however,  much  more  severe  and  hurtful  influences  must 
cooperate  before  the  breakdown  can  occur.  Savage  remarks 
that  general  paresis  is  almost  unknown  in  the  Scottish  High- 
lands, as  well  as  in  the  country  districts  of  Ireland  and  Wales, 
but,  he  adds,  it  would  be  an  error  to  deduce  that  an  immunity 
exists  for  the  people  living  there,  for,  as  soon  as  these  simple 
folk  leave  their  homes  to  settle  in  large  cities,  their  apparent 
immunity  is  broken  down  under  the  exhausting  life  of  their 
new  surroundings.  The  factors  which  in  this  instance  cooperate 
to  cause  the  breakdown  are  syphilis,  aided  by  the  restless  over- 

73 


74   THE  UNSOUND  MIND  AND  THE  LAW 

activity  of  modern  life,  insufficient  relaxation,  and  the  excesses 
of  eating  and  drinking. 

Similar  observations  may  be  made  in  relation  to  all  people 
still  living  in  the  state  of  nature.  In  them  pronounced  insanity 
is  encountered  very  infrequently.  This,  however,  is  so  not  be- 
cause they  are  immune  but  because  of  other  easily  determinable 
reasons.  Some  of  these  peoples,  as  the  Indians  of  Northern 
Canada,  put  their  insane  to  death ;  others,  even  more  inhumane, 
leave  them  without  protection  so  that  sooner  or  later  they  must 
perish.  If  the  alleged  immunity  of  savages  be  put  to  the  test 
by  exposing  them  to  the  same  damaging  influences  which  cus- 
tomarily produce  insanity  in  civilized  peoples,  it  will  be  found 
that  they  are  no  less  susceptible.  Were  they  really  immune 
the  changes  of  environment  alone  would  not  be  capable  of 
producing  insanity,  since  thousands  of  people  are  daily  able  to 
maintain  themselves  under  unaccustomed  conditions  without 
suffering  any  noticeable  impairment  of  mental  integrity. 

Racial  immunity,  or  any  other  congenital  insusceptibility  to 
mental  disease,  therefore  does  not  exist.  In  a  general  way,  in 
comparing  two  persons  equally  free  from  inherited  taint  and 
each  possessing  a  normally  resisting  brain,  we  can  only  say 
that  the  one  who  lives  by  his  muscles  will  be  in  less  danger  of 
becoming  insane  than  the  one  who  lives  by  his  brain ;  and,  to 
carry  the  contrast  further,  that  life  in  the  country  exposes  people 
less  to  mental  disorder  than  does  life  in  the  large  cities  with 
its  nerve-racking  struggle  for  existence  and  enervating  life  of 
luxury.  People  occupied  in  farming  tend  less  to  the  develop- 
ment of  insanity  because  the  demands  made  upon  their  brains 
are  less,  and  because  they  are  less  tempted  to  give  up  to  injurious 
forms  of  amusement  the  time  that  should  be  devoted  to  sleep 
and  recuperation. 

Moreover,  the  development  of  the  body  is  usually  less  ham- 
pered in  farming  centers  than  it  is  in  large  cities.  Children 
brought  up  in  the  country  need  not  acquire  the  amount  of 
school  learning  demanded  of  city-bred  children,  and  hence 
they  are  started  at  work  much  earlier.  The  city-bred  child, 
though  advanced  in  school  learning,  will  often  be  backward  in 
physical  development  and  consequently  will  be  less  fitted  for 
the  struggle  for  existence.  Of  what  use  are  our  child  labor  laws 
if,  while  protecting  the  child  from  the  ill  effects  of  premature 


EXOGENOUS  CAUSES— MENTAL  DISORDER     75 

physical  exertion,  they  cause  it  to  he  overburdened  in  school 
work?  That  country  children  usually  show  the  better  develop- 
ment certainly  speaks  for  the  fact  that  mental  overburdening 
is  more  harmful  than  bodily  exertion.  Moreover,  the  circum- 
stance that  the  farmer,  although  actually  working  harder  than 
the  factory  hand  or  city  business  man,  much  less  frequently 
sacrifices  his  mental  stability,  proves  that  the  disposition  to 
mental  disorder  grows  with  the  complexity  of  extrinsic  condi- 
tions. The  truth  of  this  statement  is  also  corroborated  by  an 
analysis  of  the  statistics  of  suicides.  These  teach  us  that  sui- 
cide in  both  sexes  is  proportionately  more  common  in  cities 
than  in  the  country,  and  in  large  cities  than  in  small  ones.  In 
the  latter  the  proportion  is  almost  twice  that  of  the  country. 

Environment  and  pursuit,  therefore,  are  among  the  most 
important  extrinsic  productive  causes  of  mental  disease,  for 
unfavorable  conditions  of  life  will  promote  a  disposition  to  men- 
tal disorder,  even  when  no  trace  of  inherited  mental  taint  exists. 
On  the  other  hand,  as  I  have  already  said,  it  is  very  possible 
that  under  favorable  environment  a  psychopathic  taint  of  slight 
degree  will  not  develop  but  will  remain  latent.  Hence  a  person 
may  remain  healthy  though  primarily  disposed  to  mental  dis- 
order, while  on  the  other  hand  a  person  possessing  a  congeni- 
tally  healthy  nervous  system  may  become  insane. 

The  condition  of  life  which  must  be  considered  ' '  favorable ' '  or 
"unfavorable"  cannot  be  precisely  defined.  Whatever  is  adapt- 
ed to  a  person's  individuality  is  favorable;  whatever  is  opposed 
to  it  is  "unfavorable."  "What  is  "favorable"  for  one  person 
may  be  ' '  unfavorable ' '  for  another.  Thus,  as  I  have  shown  upon 
another  occasion,  the  question  of  school  overburdening  is  an 
entirely  relative  one.  The  same  instruction  that  represents  an 
excellent  means  of  developing  the  mental  faculties  in  a  talented 
pupil  may  be  a  source  of  psychic  disorder  to  a  pupil  of  less 
endowment.  Similar  conditions  govern  the  environment  in  which 
chance  has  placed  us.  Whatever  our  atmosphere,  life  makes 
a  certain  demand  upon  us,  and  what  one  person  can  accomplish 
with  the  greatest  ease  may  be  an  insupportable  burden  for 
another.  It  is  not  alone  the  magnitude  of  the  demands  that 
stamps  the  surroundings  as  favorable  or  unfavorable,  but  the 
fact  of  the  individual's  capabilities  being  adequate  for  the  ful- 
filment of  the  allotted  task. 


76       THE  UNSOUND  MIND  AND  THE  LAW 

When  a  person  becomes  insane,  though  without  any  inherited 
predisposition  and  in  the  apparent  absence  of  extrinsic  causes 
such  as  head  injury,  infections,  etc.,  the  question  will  naturally 
arise  whether  the  breakdown  is  not  the  result  of  persistent 
overexertion.  That  the  same  amount  of  exertion  in  another 
person  would  constitute  merely  an  exercise  of  his  normal  activ- 
ity does  not  of  course  answer  the  question.  A  person  is  not 
necessarily  inferior  because  a  certain  task  that  another  can 
accomplish  with  ease  is  beyond  him.  His  own  endowment  merely 
lies  in  another  direction.  But  it  has  already  been  shown  that 
persistent  suppression  of  a  person's  individuality  by  constant 
work  in  a  field  which  has  no  attractions  for  him  may  ultimately 
lead  to  a  breakdown.  Nevertheless  such  instances  are  com- 
paratively infrequent.  As  a  rule  the  external  conditions  of 
life  (environment)  create  a  disposition  to  insanity  only  when 
the  central  nervous  system  has  already  been  an  inferior  one. 
This  also  holds  true  for  other  extrinsic  causes.  There  are  in- 
numerable persons  who  are  in  constant  combat  with  disturbances 
of  all  kinds,  who  are  tortured  by  grief  and  trouble,  pursued 
by  misfortune  and  harassed  by  disappointment,  and  who  remain 
mentally  healthy  in  spite  of  all  these  mishaps.  Innumerable 
persons  have  sustained  injuries  to  the  head  and  have  passed 
through  exhausting  disease  without  losing  their  mental  balance. 
Furthermore,  how  many  persons  are  there  who  commit  all 
kinds  of  excesses  in  Baccho  and  in  Venere  and,  who  even  though 
they  may  have  infected  themselves  during  their  debauches,  still 
maintain  their  psychic  efficiency?  And  how  many  who,  not- 
withstanding a  generalized  arteriosclerosis,  remain  mentally 
alert  into  the  most  advanced  age? 

If  of  two  persons  of  equal  age,  both  arteriosclerotic,  but  other- 
wise well,  one  goes  into  a  state  of  mental  decline  while  the  other 
remains  mentally  active ;  if  of  two  persons  who  become  syphiliti- 
cally  infected  one  develops  paresis  while  the  other  never  shows 
any  other  than  the  physical  symptoms  of  the  lues;  if  of  two 
chronic  alcoholics  in  their  alcohol-free  periods  one  becomes 
mentally  disturbed  while  the  other  remains  mentally  clear;  if  of 
two  persons  who  pass  through  a  carbonic  oxide  intoxication,  a 
typhoid  or  some  other  exhausting  disease  the  one  becomes  ap- 
parently demented  as  a  result  of  his  illness  while  the  other 
retains  his  complete  mental  integrity — then  the  different  effect 


EXOGENOUS  CAUSES— MENTAL  DISORDER     77 

of  one  and  the  same  cause  in  the  various  patients  can  he 
explained  only  upon  the  assumption  of  the  existence  of  a  dif- 
ferent resistibility  of  the  brain.  In  the  one  person  the  brain 
constitutes  the  locus  minoris  resistentice,  the  weak  point,  which 
cannot  withstand  the  attack  of  the  disease,  while  in  the  other, 
the  brain  is  to  a  certain  degree  immune.  "Were  this  not  so, 
then  the  same  damaging  influences  should  have  the  same  in- 
fluence upon  the  brain  in  all  of  them.  We  must,  therefore,  reach 
the  conclusion  that  in  general  neither  a  psychopathic  taint  in 
itself,  nor  an  extrinsic  cause  in  itself,  will  be  sufficient  for  the 
production  of  insanity  but  that  both  must  cooperate  to  bring 
about  this  result. 

Dissipation  as  a  factor  in  the  production  of  insanity  represents 
for  our  consideration  a  special  circulus  vitiosus.  It  is  admitted 
by  most  psychiatrists  that  a  person  does  not  become  insane 
because  he  leads  a  dissipated  life,  but  he  becomes  dissipated 
because  he  has  an  abnormal  brain.  The  healthy  organism  revolts 
against  an  excess  of  any  kind,  but  we  must  bear  in  mind  that 
what  constitutes  an  excess  for  one  individual  may  well  represent 
a  normal  limit  for  another.  Alcoholic  abuses  and  sexual  aber- 
rations carried  to  an  unnatural  degree  point  with  certainty  to 
an  abnormal  brain.  The  more  a  dissipated  life  undermines  the 
psychic  powers,  the  more  will  the  abnormal  brain  crave  new 
stimulants,  the  supply  of  which  in  turn  will  aid  in  producing 
ruin  of  body  and  mind  until,  finally,  complete  collapse  ensues. 
This  same  disastrous  mutational  activity  may  be  noted  in  regard 
to  masturbation.  He  who  gives  himself  up  to  unbridled  mastur- 
batory  excesses  has  an  inferior  nervous  system,  as  also  have, 
homosexual  individuals.  Even  when  the  dangers  of  their 
transgressions  are  explained  to  them,  the  persons  so  addicted 
are  unable  to  master  their  passion.  The  inferior  nervous  sys- 
tem is  the  cause  of  a  pathological  weakness  of  the  will  which 
cannot  be  overcome  by  a  recognition  of  the  evils  produced  by 
the  dissolute  mode  of  life;  and  following  the  diseased  impulses 
with  less  and  less  resistance,  the  damage  to  the  nervous  system 
grows  apace  and  the  loss  of  will  power  becomes  greater  and 
greater. 

The  statement  that  extrinsic  causes  alone  generally  do  not  suf- 
fice to  produce  psychic  disease  is  of  fundamental  significance  for 
an  understanding  of  the  origin  and  development  of  such  dis- 


78       THE  UNSOUND  MIND  AND  THE  LAW 

order.  I  admit  that  exceptionally  the  most  resistant  brain  may 
be  permanently  weakened  by  overexertion,  emotional  excite- 
ment, and  bodily  disease  which  also  involves  the  brain  and  its 
membranes,  but  we  must  not  retreat  from  the  position  that  in 
the  great  majority  of  instances  the  extrinsic  causes  could  impli- 
cate the  brain  only  because  there  they  found  a  vulnerable  point 
of  attack.  Where  this  locus  minoris  resistentice,  is  wanting,  the 
brain  under  entirely  similar  conditions  will  remain  unaffected. 
Etiologically,  therefore,  stress  should  be  laid  not  upon  extrinsic 
causes  but  upon  the  psychopathic  taint.  The  latter  constitutes 
the  most  favorable  basis  for  the  development  of  pathogenic 
influences. 

In  another  part  of  this  book  we  shall  see  how  apparently  re- 
mote causes,  for  instance  pregnancy  or  parturition,  may  produce 
functional  disturbances  of  brain  activity.  At  present  I  would 
but  recall  that  it  is  not  alone  the  conflict  with  law  or  morals  that 
determines  the  presence  of  a  psychosis,  but  in  the  majority  of 
instances  the  first  signs  of  mental  disorder  may  be  traced  back 
to  a  time  when  the  patient  still  complied  with  all  social  and 
ethical  obligations. 

The  older  definition  of  insanity  which  explains  it  as  a  trans- 
formation of  the  personality,  a  falsification  of  the  ego,  has  its 
full  justification.  These  terms  convey  the  idea  that  psychoses 
as  a  rule  do  not  arise  suddenly  and  without  premonition,  but 
gradually  develop  from  small  beginnings. 

Usually  at  the  commencement,  only  slight  peculiarities,  ec- 
centricities or  oddities  are  noticeable.  These  gradually  gain 
more  and  more  ascendency  over  the  ideational,  emotional  and 
volitional  activities.  Mental  disease  in  any  particular  individual 
may  be  recognized  by  the  differences  and  changes  in  habits,  by 
the  altered  likes  and  dislikes  and  emotions,  as  well  as  by  other 
signs  of  a  change  in  the  nerve  centers.  The  transformation  from 
mental  health  to  mental  disorder  covers  a  varying  period  of 
time.  Hence  the  only  gage  of  an  individual's  health  is  his  own 
normal  state.  No  person  should  be  called  mentally  sound  or 
unsound  except  as  compared  to  himself  in  a  state  of  health. 
I  recall  this  fact  in  order  to  controvert  the  widespread  opinion 
that  health  and  disease  are  radically  different.  They  differ 
radically  only  when  the  transition  from  one  to  the  other  takes 
place  very  rapidly,  an  occurrence  which,  as  already  stated,  is 


EXOGENOUS  CAUSES— MENTAL  DISORDER     79 

infrequent.  In  all  other  instances  the  recognition  that  a  brain 
is  inferior  is  equivalent  to  the  recognition  of  the  commencement 
of  the  psychosis.  It  is  the  psychopathic  taint  which  permits  the 
effects  of  otherwise  harmless  influences  to  become  injurious.  In 
order,  however,  to  answer  the  question  why  one  child  in  a  fam- 
ily may  be  psychopathically  tainted,  while  another  may  remain 
entirely  free  from  such  taint,  we  must  always  bear  in  mind  that 
a  child  is  not  merely  the  offspring  of  its  father  and  mother,  but 
is  the  final  constituent  of  a  long  series  of  ascendants,  and  is 
heir  to  their  varied  peculiarities  and  endowments.  Of  these 
characteristics,  one  child  inherits  one,  another  child  inherits 
some  other.  We  should  not  be  astonished,  therefore,  when,  in  a 
family  of  six  or  eight  children,  only  one  child  possesses  certain 
bodily  or  mental  peculiarities  which  are  known  to  have  been 
present  through  many  generations  in  the  family  of  the  father 
or  the  mother. 

In  concluding  this  chapter,  I  would  again  emphasize  the  fact 
that  anatomical  changes  can  but  rarely  be  regarded  as  the  cause 
of  an  insanity.  One  of  the  greatest  difficulties  with  which  the 
study  of  mental  disease  has  had  to  contend  is  that  autopsies  have 
revealed  so  few  changes  that  could  be  perceived  by  the  naked 
eye.  Even  by  the  aid  of  a  high-powered  microscope,  often  only 
the  barest  traces  of  alteration  are  discoverable  in  the  cortex 
of  the  brain.  Marked  changes  are  found  solely  in  paresis  and 
in  other  states  of  pronounced  dementia.  No  other  mental  dis- 
orders can  be  recognized  from  the  autopsy  alone.  Of  course 
we  must  assume  anatomical  lesions  to  be  the  cause  of  the  func- 
tional changes  of  the  brain  and  nervous  system,  but  at  present 
our  technical  means  of  examination  are  not  sufficiently  perfected 
to  enable  us  to  recognize  these  delicate  structural  alterations. 
The  time  will  certainly  come,  however,  when  the  connection  be- 
tween the  millions  of  brain  and  nerve  cells,  as  well  as  the  de- 
pendence of  their  normal  activity  upon  proper  nutrition,  will 
be  better  understood. 


V 

MENTAL  DISORDER  AND  RESPONSIBILITY 

A.  The  Physiologic-Psychologic  Basis  of  Responsibility 

In  the  estimation  of  the  mental  state  of  an  individual,  foren- 
sic psychiatry  lays  stress  particularly  upon  two  points : — 

In  civil  law  it  is  the  business  capacity  that  must  be  established. 

In  criminal  law  it  is  the  responsibility  that  is  to  be  established. 

Both  branches  of  the  law  presume  that  the  individual  has  a 
free  will,  i.e.,  that  he  allows  himself  to  be  guided  by  reasonable 
motives  in  all  his  actions.  In  consequence  of  pathological  states 
the  individuality  of  the  person  may  be  so  altered  that  the  ef- 
fectiveness of  normal  motives  becomes  abrogated,  either  par- 
tially or  entirely.  Then  the  free  will  (determination)  of  this 
person  has  been  partially  or  entirely  annulled.  It  must  be  the 
aim  of  every  expert  opinion  to  decide  whether  this  has  occurred. 
The  concept  of  responsibility  depends  upon  the  assumption  that 
free  volition  governs  our  acts.  It  is  a  reasonable  presumption 
that  every  normal  adult  person  is  capable  of  safeguarding  his 
own  interests.  This  constitutes  business  capacity.  In  addition 
to  the  capability  of  an  individual  to  care  for  himself,  however, 
the  law  also  assumes  that  every  person  who  has  grown  up  and 
been  trained  under  the  accepted  ethical  views  and  notions  of  our 
social  organization  shall  have  acquired  an  ample  sum  of  moral 
concepts  by  which  to  guide  his  conduct  in  life.  All  legal  statutes 
recognize  the  necessity  for  the  existence  of  the  potentiality  of 
guilt  (imputability),  the  connection  between  will  and  act,  before 
punishment  may  be  decreed.  Hence  "guilt,"  in  the  sense  of  the 
criminal  law,  may  be  directly  designated  as  that  constitution  of 
the  will  which  makes  a  person  responsible  for  a  punishable 
wrong. 

It  is  not  necessarily  true  that  every  carrier  of  a  mental  anom- 
aly will  under  all  circumstances  be  misled  by  his  morbid  im- 
pulses into  the  commission  of  a  wrong.    His  transgression  takes 

80 


MENTAL  DISORDER  AND  RESPONSIBILITY     81 

place  only  when  his  actions  are  no  longer  inhibited  by  notions 
which  would  amply  suffice  to  control  the  conduct  of  the  sensible 
persons  of  the  community  in  which  he  lives.  In  order  that  a  per- 
son who  has  committed  a  punishable  wrong  may  be  held  respon- 
sible for  his  act,  it  is  necessary  to  assume  he  possesses  sufficient 
insight  to  enable  him  to  recognize  the  punishability  of  the  un- 
lawful deed.  The  law  assumes  a  lack  of  such  insight  in  chil- 
dren, as  well  as  in  pathological  disorders  of  mental  activity,  in 
feeblemindedness  and  in  persons  who  are  unconscious.  But  it 
distinguishes  only  two  possibilities,  responsibility  and  irrespon- 
sibility, a  distinction  which  in  many  instances  seems  to  be  too 
abrupt  and  which  represents  a  practical  hardship.  As  we  have 
seen,  it  is  just  as  impossible  to  draw  a  distinct  line  between 
health  and  mental  disorder  as  it  is  to  mark  the  exact  line  between 
bodily  disease  and  bodily  health.  The  aberrations  of  mental 
health  occur  in  very  many  transitional  forms  and  mixtures,  and 
in  these  there  can  often  be  no  distinct  borderline  between  re- 
sponsibility and  irresponsibility.  In  certain  mental  disorders — 
for  instance,  in  melancholia,  mania,  paranoia,  etc. — there  can 
be  no  question  as  to  the  patient's  irresponsibility.  Once  the 
diagnosis  has  been  established  and  the  fact  of  the  commission 
of  the  offense  during  the  existence  of  the  disease  has  been  proved, 
the  question  of  the  person's  responsibility  answers  itself.  The 
general  proposition  that  an  insane  person  is  free  from  respon- 
sibility should  be  maintained. 

But  where  we  are  dealing  with  individuals  who  are  upon  the 
borderline  between  health  and  disease,  the  question  must  be  an 
entirely  different  one.  In  such  cases  proof  of  the  existence  of  a 
deviation  from  a  state  of  mental  health  is  by  no  means  synony- 
mous with  proof  of  irresponsibility.  Borderline  states  of  this 
type  may  roughly  be  divided  into  two  classes,  as  follows : 

First,  states  of  disease  only  partially  developed,  but  in  which 
a  pathological  disorder  of  the  mind  is  permanently  present. 
This  group  refers  to  individuals  in  whom  there  exist  certain 
inadequacies  and  peculiarities. 

Second,  eases  in  which  pronounced  mental  disorder  exists 
temporarily  but  not  permanently,  and  in  which  an  appreciation 
of  the  interparoxysmal  phases  becomes  exceedingly  difficult. 
To  this  group  belong  many  cases  of  epilepsy,  hysteria,  chronic 
alcoholism  and  morphinism,  as  well  as  the  afflictions  of  many  pa- 


82       THE  UNSOUND  MIND  AND  THE  LAW 

tients  who  are  in  the  early  stages  of  senile  dementia,  and  of  all 
those  who  are  in  an  interval  phase  of  a  periodic  insanity,  etc. 

It  is  for  the  latter  group  of  cases  that  the  adoption  of  the  notion 
of  restricted  responsibility  would  he  in  accord  with  all  scientific 
facts,  as  well  as  being  a  great  practical  help  alike  to  the  judge 
and  the  medical  expert.  In  all  these  states,  however,  whether 
there  he  a  question  of  the  existence  of  states  of  sleep  and  dreami- 
ness, of  hypnosis,  of  inebriety  or  of  excessive  emotion,  the  psy- 
chiatrist as  expert  must  always  bear  in  mind  that  it  is  a  long 
road  from  the  demonstration  of  the  possibility  to  that  of  the 
probability  or  the  certainty  of  a  causal  connection  between  the 
disorder  as  it  exists  and  the  deed  of  which  the  person  stands 
accused.  An  entirely  convincing  proof  of  such  connection  can 
be  furnished  alone  by  showing  that  the  deed  was  the  result  of 
a  disordered  state  of  mind,  so  disordered  that  free  deter- 
mination could  not  be  exercised.  The  lack  of  reasonable  motive, 
the  recognition  of  the  existence  of  a  disordered  state  of  mind, 
even  at  the  time  of  the  commission  of  the  deed,  would  not  suf- 
fice. Consequently  the  expert  only  too  often  will  find  it  neces- 
sary to  declare  himself  unable  to  express  an  opinion  as  to 
whether  certain  states  of  mental  disorder  do  or  do  not  annul 
free  determination  and  responsibility.  In  this  connection  I 
would  again  lay  stress  upon  the  necessity  for  considering  the 
entire  personality,  and  more  especially  for  carefully  comparing 
the  psychic  comportment  at  the  time  of  the  imputed  punishable 
deed  with  the  previous  character  of  the  accused. 

We  cannot  enter  here  upon  a  formal  inquiry  regarding  free- 
dom of  the  will  and  determination.  Because  it  is  universally 
acknowledged  that  everything  takes  place  in  accordance  with 
the  law  of  cause  and  effect,  it  by  no  means  follows  that  all  our 
doings  are  purely  mechanical  and  that  free  determination  does 
not  exist.  In  this  regard  man  differs  from  the  rest  of  the  or- 
ganic world.  Not  everything  he  does  takes  place  because  it 
must.  Upon  the  one  hand  transmitted  instincts,  training  and 
surroundings  force  his  character  and  will  to  take  a  definite 
course,  but,  upon  the  other,  they  also  produce  definite  inhibi- 
tions which  at  certain  times  will  come  into  play.  Man  can  com- 
pare the  motives  for  his  acts,  can  estimate  their  relationship  to 
each  other,  and  can  then  effect  a  choice.  Under  pathological 
conditions  and  particularly  under  the  influence  of  erroneous  no- 


MENTAL  DISORDER  AND  RESPONSIBILITY     83 

tions  and  delusions,  the  weight  of  certain  motives  will  be  falsely 
estimated  and  the  resulting  action  will  take  a  wrong  course.  But 
even  when  the  recognition  of  the  punishability  and  wrong  of  a 
deed  exists,  the  possibility  must  always  be  considered  that  a 
person's  better  appreciation  has  been  annulled  by  pathological 
impulses.  Hence  we  can  understand  why  it  is  that  one  patient 
will  lack  recognition  of  the  wrong  of  an  immoral  or  illegal 
deed,  while  another,  despite  such  recognition,  cannot  withstand 
his  immoral  impulses,  and  in  still  another  there  may  exist  a 
counter  action  of  imperative  impulses  and  obscuration  of  con- 
sciousness, etc.  To  all  this,  however,  must  be  added  a  consider- 
ation of  the  dependence  of  psychic  activity  upon  physiological 
processes.  Everything  therefore  takes  place  in  accordance  with 
the  law  of  cause  and  effect,  but  the  causes  differ  under  normal 
and  under  pathological  conditions  and  it  is  only  partially  in  our 
power  voluntarily  to  alter  these  conditions.  At  any  rate,  there 
can  exist  no  absolute  freedom  of  the  will,  but  only  a  freedom  of 
the  will  that  is  restricted  in  accord  with  the  law  of  cause  and 
effect. 

Every  jolt  of  a  kaleidoscope  will  cause  its  pattern  to  change  by 
altering  the  positions  of  the  varicolored  and  differently  formed 
particles  in  relation  to  one  another.  The  particles  in  them- 
selves remain  as  they  were ;  neither  in  form  nor  in  color  have 
they  been  changed.  Similar  conditions  seem  to  apply  in  mental 
disorder.  Change  in  a  psychic  function  alters  the  entire  mental 
impress,  gives  the  personality  another  character,  even  when 
the  individual  parts  that  constitute  psychic  activity  are  all 
present.  Therefore  it  is  not  at  all  necessary  that  one  or  the 
other  of  the  psychic  functions  should  be  eliminated  before  in- 
sanity can  be  produced.  A  machine  may  fail  to  operate  be- 
cause a  small  cog  or  wheel  is  lacking;  on  the  other  hand,  the 
machine  may  come  to  a  stop  because  one  part  or  another  of  its 
mechanism  has  become  displaced,  thereby  rendering  impossible^ 
the  proper  interlocking  of  wheels,  shafts,  etc.  Similarly  a  dis- 
order of  brain  activity  depends  only  in  part  upon  the  subversion 
of  the  individual  functions  necessary  for  the  orderly  course  of 
psychic  processes.  For  instance,  if  one  or  another  of  the  sen- 
sory organs  be  wanting,  no  complete  sensory  perception  can  be 
realized  and  a  more  or  less  pronounced  defect  in  psychic  activity 
must  ensue.    Other  manifestations  of  downfall  (loss  of  memory, 


84   THE  UNSOUND  MIND  AND  THE  LAW 

etc.)  may  be  produced  by  cerebral  hemorrhage  or  injuries  to 
important  centers  of  the  brain.  It  would  be  erroneous,  how- 
ever, to  conclude  from  any  such  occurrence  that  every  dis- 
order of  mental  activity  must  be  associated  with  the  loss  of  some 
psychic  function.  In  very  many  instances,  while  the  actual 
relationship  of  the  individual  parts  has  become  disordered,  there 
exists  no  injury  to  any  one  part  and  no  actual  defect.  A  trans- 
location has  occurred  which  has  rendered  impossible  the  proper 
interassociation  of  the  various  individual  brain  ganglia  and 
other  brain  parts. 

An  appreciation  of  this  condition  is  necessary  if  we  would 
form  any  valid  opinion  regarding  a  person's  mental  state.     The 
layman  easily  conceives  insanity  to  be  a  condition  in  which  a 
person  has  lost  the  use  of  his  reason.     We  should  not  forget, 
however,  that  the  conceptual  sphere  of  a  patient  does  not  change 
abruptly.     The  educated  and  cultured  individual  does  not  be- 
come transformed  suddenly  into  an  ignorant  and  senseless  one. 
The  business  man  does  not  suddenly  lose  his  entire  acumen,  nor 
the  mechanic  his  dexterity.     For  the  layman,  the  recognition 
of  insanity  in  an  individual  case  is  attended  with  great  difficul- 
ties, and  this  is  so  particularly  because  the  insane  frequently 
retain  sufficient  power  of  thought  and  will  to  completely  conceal 
their  altered  condition  in  all  ordinary  social  intercourse.    Often 
the  insane  person  really  believes  he  is  not  sick;  but  even  when 
he  knows  he  is  not  well  he  endeavors  to  control  himself  so  that 
no  inopportune  remark  will  escape  him.     Unfortunately  even 
to-day  all  people  look  upon  insanity  as  a  disgrace  and  not  as  an 
affliction.    Moreover,  it  is  generally  recognized  that  a  person  who 
is  insane  must  be  placed  under  control.     No  wonder  then  an 
insane  person,  so  far  as  it  lies  in  his  interest,  will  concentrate 
his  endeavors  toward  deceiving  those  with  whom  he  comes  in 
contact.     This  is  not  difficult  when  his  mental  powers  are  al- 
tered in  one  direction  only.     He  will  apparently  think  clearly 
and  logically  in  all  other  fields  and  will  by  no  means  give  the 
impression  of  being  insane,  of  being  deprived  of  his  reason. 
Likewise  there  are  insane  persons  who  not  only  have  the  will 
power  to  hide  all  their  false  ideas  but  also  are  able  with  much 
astuteness  and  cunning  to  fabricate  explanations  for  their  ab- 
normal statements  and  actions.     Then  again  we  must  consider 
that  periodic  insanity  is  often  characterized  by  intervals  of  ap- 


MENTAL  DISORDER  AND  RESPONSIBILITY     85 

parent  mental  health,  during  which  the  intelligence  and  will 
power  appear  to  be  unaffected.  Careful  observation,  however, 
will  always  reveal  the  existence  of  certain  almost  intangible  evi- 
dences of  mental  disorder,  such  as  disconnected  thoughts,  emo- 
tional excitability,  shunning  of  associates  and  acquaintances, 
distorted  views  of  existing  conditions  and  other  similar  things. 

In  so  far  as  the  classification  of  the  individual  forms  of  mental 
disorders  is  concerned,  no  uniformity  has  been  attained.  This 
to  a  great  extent  is  due  to  our  ignorance  of  the  more  delicate 
structural  changes  that  occur  in  mental  disorders.  All  we  know 
is  that  the  diseased  state  of  the  brain  constituting  the  basis 
of  mental  disease  is  essentially  a  disorder  of  the  gray  brain 
cortex  and  that  even  an  extremely  slight  physical  or  chemical 
change  of  the  brain  substance  suffices  to  produce  a  disturbance 
of  psychic  function.  For  this  reason  it  is  not  possible  to  base 
any  classification  of  mental  disorders  upon  considerations  that 
govern  the  classification  of  most  bodily  diseases.  While  the 
latter  may  be  differentiated  according  to  the  part  of  an  organ 
involved  by  the  process  of  disease,  as  for  instance  a  parenchym- 
atous or  interstitial  nephritis,  we  cannot  differentiate  mental 
diseases  according  to  this  plan,  but  must  base  our  classifica- 
tion to  a  great  extent  upon  the  symptoms  which  the  disease 
produces. 

Hence,  according  to  the  manner  of  their  manifestations, 
whether  as  augmented  or  diminished  activities  of  intellect,  will 
or  emotion,  mental  disease  may  be  classified  as  mania,  melan- 
cholia, paranoia  or  dementia.  But  these  various  forms  of  mental 
disease  by  no  means  represent  so  many  distinctly  different  dis- 
eases, for  in  many  instances  a  combination  of  several  states  is 
present,  or  the  one  follows  the  other  as  a  sequential  stage  of  one 
and  the  same  mental  sickness. 

Mental  disorders  may  also  be  classified  as  primary  or  sec- 
ondary. In  the  former  class  as  a  rule  intelligence  (perception, 
thought  association  and  judgment)  is  less  disordered  than  the 
emotion  and  the  will.  On  the  other  hand,  the  symptoms  of  sec- 
ondary mental  disorders  are  predominantly  intellectual  ones. 
The  power  of  thought  and  judgment  is  diminished.  Everything 
appears  to  the  patient  as  if,  so  to  say,  he  were  looking  into  a 
parabolic  mirror.  He  of  course  sees  only  distorted  images,  and, 
while  under  similar  conditions  a  healthy  person  knows  that  the 


80       THE  UNSOUND  MIND  AND  THE  LAW 

images  are  distorted,  the  insane  person  considers  them  to  be 
true  and  accurate  and  his  deductions,  which  may  be  quite  logical, 
will  necessarily  be  based  upon  this  belief.  His  entire  behavior 
is  based  upon  an  erroneous  premise.  Having  lost  his  standard  of 
judgment  for  actual  occurrences,  he  exaggerates  inordinately 
both  pain  and  pleasure.  Naturally  the  degree  of  culture  pos- 
sessed by  an  individual  must  have  a  bearing  upon  the  extent 
of  the  intellectual  defect;  the  apperceptional  power,  however, 
also  has  become  abnormal,  and  the  consciousness  clouded  and  in- 
creasingly dominated  by  the  delusions  which  ultimately  alter 
and  transform  the  individual's  entire  personality.  Then  the 
psychosis  is  fully  developed  and  the  exercise  of  the  intellect 
with  free  determination  of  the  will  is  no  longer  possible. 

While  the  primary  mental  diseases,  when  recognized  early  and 
properly  treated,  often  present  prospects  of  recovery,  the  sec- 
ondary psychoses,  those  which  result  from  the  primary  ones,  are 
usually  permanent  states.  In  a  general  way  it  may  be  said,  re- 
covery will  be  the  more  uncertain  the  longer  the  psychosis  has 
existed.  Much  therefore  depends  upon  early  recognition  of  the 
disordered  condition. 

The  earliest  manifestations  represent  a  marked  emotional 
change.  A  gentle  and  docile  person  becomes  surly  and  irritable, 
the  sedate  and  sober  one  boisterously  joyous,  the  parsimonious 
one  extravagant,  etc.  The  person  of  a  cheerful  temperament  be- 
comes quiet,  depressed  and  quarrelsome ;  he  wants  to  be  left 
alone,  becomes  unsociable,  and  for  long  periods  of  time  sits 
lost  in  thought.  He  gives  little  or  no  attention  to  his  business 
or  his  family  and  what  little  he  does  is  usually  purposeless  and 
disordered.  He  is  distraught,  neglectful  and  incapable  of  con- 
centration. He  tires  easily  and  sleeps  restlessly.  He  is  un- 
ceasingly pursued  by  a  single  thought  which,  the  more  his  in- 
tellectual powers  diminish,  gains  more  and  more  dominance 
over  his  enfeebled  will  power.  In  another  patient  thought 
images  are  plentifully  present  and  change  rapidly,  but  the 
transition  from  one  to  another  is  abrupt  and  not  by  any  means 
through  orderly  thought  association.  Very  many  patients  grow 
markedly  excited  over  insignificant  causes,  while  the  most  im- 
portant occurrences  leave  them  unconcerned  and  unaffected. 

The  more  the  diseased  process  advances,  the  more  noticeable 
do  these  symptoms  become.     The  patient's  behavior  becomes 


MENTAL  DISORDER  AND  RESPONSIBILITY     87 

tactless  and  changeable.  His  actions  are  causeless  and  unrelated 
or  are  governed  by  purposes  and  motives  that  are  contradictory, 
opposed  to  his  own  interests  and  incomprehensible  to  a  normal 
person.  Frequently  he  craves  the  impossible,  aspires  to  im- 
mense riches  or  wants  to  be  a  great  inventor  or  a  general  re- 
former. He  feels  himself  chosen  to  endow  the  world  with  a  new 
social  order  or  to  accomplish  some  other  great  feat.  The  patient 
may  be  joyous  and  excited  without  adequate  cause.  Then  again 
he  may  be  overcome  by  an  apparently  causeless  depression,  often 
so  intense  that  it  leads  to  suicide.  Sometimes  he  causes  injury 
to  himself  or  others  without  having  any  idea  that  he  may  be 
held  legally  responsible  for  his  acts. 

On  the  other  hand,  he  may  have  full  appreciation  of  his  re- 
sponsibility but,  dominated  by  a  delusion  or  an  irresistible  pres- 
sure, he  will  commit  a  crime  based  upon  a  preconceived  plan. 
He  suffers  from  headache,  tinnitus  and  other  sensory  irritations, 
often  from  complete  loss  of  appetite,  and  sometimes  inordinate 
voracity.  In  one  instance  the  sexual  desire  may  be  almost  or 
entirely  lost,  while  in  another  it  is  immoderately  augmented. 
More  and  more  easily  the  patient  loses  his  self-control,  his  actions 
form  an  ever-growing  contrast  to  his  previous  mode  of  life, 
and  his  sympathies  and  antipathies  to  his  original  character. 

In  the  chapter  on  special  diagnosis  this  development  of  the 
various  forms  of  insanity  from  small  beginnings  to  accentuated 
psychoses  will  be  considered  in  all  its  details.  I  expect  espe- 
cially to  show  how,  in  the  different  stages  and  forms  of  mental' 
disorder,  freedom  of  the  will  and  responsibility  may  be  vari- 
ously restricted,  even  when  a  pronounced  intellectual  defect  is 
in  no  way  demonstrable. 

The  early  recognition  of  mental  disorder  is  not  only  more 
important,  but  it  is  also  more  difficult  than  is  the  recognition 
of  bodily  disease,  for,  as  we  have  stated,  the  alterations  in 
thought,  feeling,  volition  and  conduct  must  have  been  present  for 
a  long  time  before  the  defective  nervous  system  could  break 
down  under  any  test  of  strain  or  stress.  The  struggle  for  ex- 
istence brings  to  light  many  psychoses  that  otherwise  might  have 
remained  unrevealed.  We  should  not  wait,  however,  until  it 
is  too  late,  until  a  person  proves  himself  no  longer  capable  of 
fulfilling  the  duties  that  devolve  upon  him.  The  expert  proves 
his  mastership  by  his  ability  to  make  a  correct  diagnosis  at  the 


88       THE  UNSOUND  MIND  AND  THE  LAW 

very  beginning,  before  generally  noticeable  symptoms  have  ap- 
peared. 

B.  Mental  Disorder  as  a  Physical  Disease 

The  disorders  of  mental  activity  are  in  the  main  disorders  of 
bodily  activity.  The  latter  are  related  not  only  to  the  central 
nervous  system  but  also  to  general  cell  metabolism,  internal  se- 
cretions, etc.,  so  that  finally,  should  the  brain  become  secondarily 
involved,  disease  of  any  organ  or  any  part  of  the  body  may 
become  the  starting  point  for  a  psychosis.  This  will  become  all 
the  more  evident  the  more  intensively  we  occupy  ourselves  with 
the  study  of  mental  disorders. 

Very  recently  the  early  recognition  of  mental  disease  has  been 
facilitated  by  a  method  which  in  all  probability  has  a  great 
future.  This  method  is  based  upon  the  defensive  ferments  dis- 
covered by  Abderhalden.  This  investigator  found  the  blood  of 
pregnant  women  to  contain  ferments  that  had  not  been  present 
previous  to  the  condition  of  pregnancy,  and  that  are  never  found 
in  the  blood  plasma  of  women  who  are  not  pregnant.  He  then 
extended  his  investigations  to  the  infectious-toxic  processes,  and 
discovered  that  the  body  cells  always  respond  to  the  entrance  of 
materials  foreign  to  these  cells  by  the  formation  of  specific  de- 
fensive ferments.  As  soon  as  the  function  of  an  organ  is  dis- 
turbed by  the  entrance  of  foreign  cells,  ferments  arise  which 
tend  to  rob  the  substance  formed  by  the  foreign  cells  of  their 
specific  character  and  so  to  transform  them  that  they  can  no 
longer  interfere  with  normal  cell  metabolism.  What  gives  the 
defensive  ferments  special  diagnostic  significance,  according  to 
Abderhalden,  is  the  fact  that  they  are  directed  specifically 
against  foreign  invaders  and  therefore  in  each  instance  differ  in 
disposition.  From  their  effectiveness  we  are  able  with  great  cer- 
tainty to  determine  the  nature  and  kind  of  the  foreign  invaders 
—in  other  words,  of  the  disease-producing  substance. 

For  instance,  as  soon  as  we  find  in  the  blood  serum  those  de- 
fensive ferments  which  are  specifically  directed  toward  the 
chorionic  epithelia,  the  proof  of  the  existence  of  pregnancy  is 
furnished,  for  only  under  such  circumstances  can  the  chorionic 
epithelia  enter  the  circulation.  These  chorion  cells,  although  not 
foreign  to  the  body  itself,  are  foreign  to  the  blood,  and  the  or- 


MENTAL  DISORDER  AND  RESPONSIBILITY     89 

ganism  therefore  reacts  to  their  entrance  into  the  blood  by  the 
formation  of  specific  defensive  ferments,  and  this  it  does  at  a 
time  when  perhaps  no  positive  signs  of  pregnancy  are  yet  demon- 
strable. For  we  must  admit  the  possibility  of  the  entrance  of 
chorionic  epithelia  into  the  circulation  during  the  earliest  months 
of  embryonal  development — hence  at  a  time  when  the  objective 
recognition  of  pregnancy  is  difficult,  if  not  actually  impossible. 
Just  as  it  responds  to  the  presence  of  chorion  cells,  so  the 
organism  reacts  to  the  invasion  of  other  foreign  blood  substances, 
namely,  by  the  formation  of  specific  defensive  ferments.  Thus, 
by  the  aid  of  these  defensive  ferments,  we  are  able  to  elaborate 
a  method  of  diagnosis  of  an  organ's  function,  because  every  dis- 
turbance of  its  function  causes  the  affected  organ  to  produce  its 
specific  defensive  ferment  and  causes  it  to  do  so  before  the 
pathogenic  state  becomes  recognizable  through  manifest  symp- 
toms. 

These  explanatory  remarks  have  seemed  to  me  to  be  requisite, 
since  without  them  the  bearing  which  Abderhalden 's  theory 
has  upon  the  diagnosis  of  mental  disorders  would  not  be  com- 
prehensible. After  it  had  been  ascertained  that  the  organism 
reacts  to  every  pathogenic  agency  by  the  formation  of  specific 
defensive  ferments,  it  was  but  natural  that  their  presence 
should  also  be  sought  in  those  diseases  of  the  mind  and  nervous 
system  that  possibly  are  due  to  toxic  infectious  processes.  The 
elaboration  of  a  serology  of  nervous  and  mental  diseases  was 
therefore  attempted  and  this  led  to  the  discovery  that  the  blood 
plasma  in  purely  functional  neuroses  and  psychoses  contained 
no  defensive  materials  whatsoever.  This  finding  was  to  have 
been  expected,  for  we  know  of  no  foreign  substance  which  causes 
purely  functional  disorders  and  which  could  incite  an  organism 
to  the  production  of  defensive  ferments.  On  the  other  hand, 
the  blood  plasma  of  patients  belonging  to  the  dementia  praecox 
group,  that  of  certain  epileptics,  that  of  myxedematous  patients 
and  of  paretics,  etc.,  as  well  as  that  of  those  suffering  from  other 
syphilitic  brain  changes,  was  shown  to  contain  specific  defensive 
ferments.  Their  presence  in  the  blood  serum  has  also  been  proved 
in  cretinism,  infantilism,  acromegaly,  katatonia,  hypophyseal 
tumors  and  all  other  mental  and  nervous  disorders  for  which 
body  foreign,  blood  foreign  or  cell  foreign  materials  are  of 
etiological  significance, 


90       THE  UNSOUND  MIND  AND  THE  LAW 

A  study  of  these  defensive  ferments  is  of  great  importance 
for  the  psychiatric  expert.  Above  all  it  becomes  possible  by 
their  aid  to  make  a  diagnosis  at  a  time  when  clinical  observation 
will  fail  to  reveal  any  positive  symptom  by  means  of  which  a 
definite  disease  can  be  recognized,  and  moreover  their  presence 
should  often  enable  the  differential  diagnosis  between  obscure 
cases  to  be  made.  The  determination  of  the  presence  of  a  cer- 
tain defensive  ferment,  either  optically  or  by  means  of  the 
dialysation  method,  always  points  to  a  specific  pathogenic  in- 
vasion, the  defensive  ferment  against  hypersecretion  of  the 
tigroid  gland  being  different  from  that  against  the  absence  of 
thyroid  secretion,  that  against  hyperpituitarism  being  different 
from  that  against  dispituitarism  and  that  of  dementia  paralytica 
being  different  from  that  against  dementia  of  any  other  kind. 
These  various  findings  have  been  corroborated  by  numerous  ob- 
servers. While  I  by  no  means  believe  that  the  Abderhalden 
method  of  blood  examination  of  itself  is  as  yet  adequate  for 
diagnostic  purposes,  I  am  convinced  that  it  is  a  valuable  ampli- 
fication of  our  methods  of  psychiatric  examination.  I  cannot 
endorse  the  enthusiasm  of  certain  authors  who  look  upon  Abder- 
halden's  method  of  diagnosis  as  an  infallible  means  of  recogniz- 
ing every  psychosis  and  every  other  pathological  state.  Clinical 
observation,  together  with  all  other  methods  of  examination,  will 
be  as  much  needed  in  the  future  as  they  have  been  in  the  past. 
The  blood  test  for  defensive  ferments  when  used  in  conjunction 
with  our  other  and  older  tests  undoubtedly  will  prove  to  be  a 
Very  important  diagnostic  adjuvant.  Abderhalden 's  method, 
however,  is  still  at  the  commencement  of  its  development. 

Entirely  aside  from  Abderhalden 's  deductions,  and  before 
proceeding  to  a  consideration  of  special  diagnosis,  we  should  ob- 
tain a  clear  understanding  of  the  mode  of  action  of  the  defensive 
ferments.  For  this  purpose  let  us  examine  more  carefully  cer- 
tain doctrines  which  play  an  important  role  in  modern  physiology 
and  pathology.  It  has  long  been  known  that  certain  psychoses  are 
dependent  upon  toxamiia  and  that  the  toxic  material  which  thus 
causes  harm  to  the  function  of  the  brain  may  be  carried  in  from 
the  outside  or  may  be  formed  in  the  body  itself.  The  sources 
of  poisoning  from  within  the  organism  are  above  all  the  poison- 
ous products  of  metabolism,  such  as  carbonic  acid,  urea,  etc., 
which  under  normal  conditions  are  eliminated.     The  excretion 


MENTAL  DISORDER  AND  RESPONSIBILITY     91 

of  these  toxic  metabolic  products  may  be  hindered  by  disease  of 
the  respiratory  and  circulatory  organs  or  by  disorder  of  the 
intestinal  tract  and  kidneys,  so  that  they  accumulate  in  the  body 
and  are  carried  to  the  brain  by  means  of  the  circulation.  A 
second  cause  of  endogenetic  poisoning  must  be  sought  in  the 
bacterial  metabolic  activity  which,  in  the  course  of  infectious 
diseases,  causes  not  only  transitory  febrile  delirium,  but  often 
also  carries  more  lasting  harm  to  the  functions  of  the  brain.  It 
is  even  possible  that  the  toxic  metabolic  processes  of  those  bac- 
teria which  inhabit  the  human  mouth,  or  of  those  that  thrive 
in  the  intestines  without  producing  any  symptom  of  disease,  will 
become  resorbed  by  the  mucous  membrane  and  produce  a  state 
of  endogenous  intoxication  with  deleterious  consequences  for  the 
central  nervous  system.  This,  as  we  have  said,  is  all  well  known. 
More  recent  investigators,  however,  have  brought  to  light  an 
additional  source  of  auto-intoxication.  There  exist  a  number  of 
ductless  glandular  organs  that  secrete  important  substances 
which  are  at  once  drained  into  the  circulation  by  means  of  the 
veins  or  lymphatics.  The  most  important  of  the  glands  with 
internal  secretion  are  the  spleen,  the  thyroid  and  parathyroid, 
the  thymus  and  hypophysis  cerebri,  the  adrenals,  the  epididy- 
mides and  the  parovarii.  The  products  of  these  glands  are  of  the 
utmost  importance  for  the  maintenance  and  activities  of  the  en- 
tire organism,  inasmuch  as  the  lack  of  any  one  of  these  products 
at  once  produces  symptoms  of  failure.  The  product  of  each 
gland  possesses  specific  qualities  which  cannot  ^be  replaced  by 
any  other  internal  secretion,  and  all  of  these  secretions  combined 
give  the  blood  that  composition  which  it  needs  as  the  nutritive 
fluid  of  the  entire  body.  A  lack  of  any  one  of  these  secretions 
will,  therefore,  bring  about  a  qualitative  alteration  of  the  blood 
resulting  in  a  curtailment  of  its  nutritive  properties.  Some 
function  of  the  blood  pertaining  to  metabolism  is  lost.  Further- 
more it  must  be  considered  that  these  internal  glandular  secre- 
tions hold  one  another  in  check  through  antagonistic  relations 
which  exist  among  them.  Therefore,  when  any  specific  internal 
secretion  becomes  lost,  its  antagonist  gains  supremacy.  Thus  it 
has  been  shown  that  uterine  secretion  and  ovarial  secretion  main- 
tain an  equilibrium  between  each  other.  Moreover,  the  nervous 
disturbances  of  the  climacteric  are  dependent  upon  the  failure 
of  ovarial  secretion.     Through  the  natural  extinction  of  ovarial 


92       THE  UNSOUND  MIND  AND  THE  LAW 

function  (or  through  artificial  climacteric  produced  by  ovariot- 
omy) the  antagonist  of  the  uterine  secretion  is  removed.  That 
the  resulting  disturbances  are  actually  dependent  upon  a  dis- 
ordered balance  of  internal  secretion,  is  incontrovertibly  proven 
by  the  prompt  action  produced  by  the  administration  of  animal 
ovarial  extract  which  acts  as  a  substitute  for  the  lost  ovarial 
secretion  and  reestablishes  the  normal  balance. 

The  mutational  relation  that  the  organs  of  internal  secretion 
bear  to  one  another  and  to  the  activities  of  the  entire  organism 
were  first  recognized  through  the  loss  of  thyroid  function  and 
through  the  cure  of  myxoedema  effected  by  the  administration 
of  animal  thyroid  gland  extract.  This  balance  of  internal  secre- 
tion becomes  disordered,  however,  not  only  in  consequence  of  a 
stoppage  or  a  diminution  of  a  certain  secretion,  but  also  through 
its  hypersecretion.  Thus  we  know  that  the  nervous  disorders 
of  exophthalmic  goiter  must  be  attributed  to  an  overactivity  of 
the  thyroid  gland.  In  this  case  the  antagonistic  glandular  organ 
is  unable  to  neutralize  the  excessive  thyroid  secretion.  Auto- 
intoxication of  the  body,  therefore,  takes  place  through  a  dis- 
turbance of  the  balance  existing  between  the  internal  secretions, 
thus  causing  a  failure  in  the  supply  of  one  neutralizing  product, 
or  causing  the  excessive  production  of  another,  so  that  the 
poisons  which  are  formed  in  the  organism  by  metabolic  or  in- 
fectious toxic  processes  can  no  longer  be  transformed  into  harm- 
less combinations. 

Internal  secretion,  therefore,  forms  part  of  the  organism's 
natural  means  of  protection  and  defense,  part  of  those  disposi- 
tions through  which  the  body  regulates  its  activity  and  seeks  to 
reestablish  their  healthy  balance  when  they  become  disordered. 
Under  altered  vital  conditions  specific  secretions  are  at  once 
mobilized  and  it  is  then  their  task  to  defend  the  function  which 
is  in  danger  against  inimical  attack.  In  the  disorders  of  the 
climacteric,  altered  conditions  of  life  are  brought  about  by  the 
loss  of  ovarial  secretion,  just  as  in  cretinism  or  myxoedema 
they  are  dependent  upon  the  loss  of  thyroid  secretion,  or  in 
exophthalmic  goiter  they  are  dependent  upon  the  hypersecre- 
tion of  the  thyroid  gland.  Soon  there  are  produced  in  the  body 
those  protective  substances  which  Abderhalden  has  designated 
as  defensive  ferments.  In  the  manifestations  of  the  climacteric 
due  to  failure  of  function,  the  defensive  ferments  are  directed 


MENTAL  DISORDER  AND  RESPONSIBILITY     93 

specifically  against  the  uterine  secretion,  in  the  manifestations 
of  cretinism  and  myxoedema,  they  are  directed  specifically 
against  the  metabolic  poisons  which  in  a  normal  state  are  neu- 
tralized by  the  thyroid  secretion,  in  exophthalmic  goiter  they 
counteract  the  thyroid  function,  etc.  Abderhalden  supposes 
that  the  defensive  ferments  arise  from  the  white  blood  cells.  He 
admits  that  their  nature  is  not  yet  understood  and  that  they  can 
be  recognized  only  by  their  effects.  Of  course  the  defensive 
ferments  cannot  always  reestablish  an  equilibrium  of  the  secre- 
tions when  it  has  been  lost  nor  restore  the  functional  changes 
which  its  disturbance  has  produced.  Were  thjs  possible  no 
sickness,  except  as  a  result  of  injury,  could  exist. 

For  the  purpose  of  our  present  inquiry  we  are  interested  not 
in  the  prophylactic  and  the  therapeutic  but  in  the  diagnostic 
value  of  the  defensive  ferments.  These  ferments  can  be  demon- 
strated in  the  blood  at  a  very  early  moment  after  the  onset  of  a 
disorder,  at  a  time  even  when  such  disorder  has  given  no  ap- 
preciable external  evidence  of  altered  function.  They  continue 
to  be  present  so  long  as  the  disorder  persists.  "When  the  regula- 
tory provisions  of  the  organism  are  able  to  cope  with  the  dis- 
order or  when  the  process  of  disease  has  run  its  course  or  has 
been  artificially  arrested,  the  defensive  ferments  again  disappear 
from  the  blood.  Thus  far  it  has  been  demonstrated  that  every 
chemical  or  morphological  alteration  of  cell  structure  is  followed 
by  the  formation  of  defensive  ferments,  which  means  that  the 
organism  responds  by  defensive  measures  to  every  disturbance 
of  equilibrium  of  its  vital  activities.  Previously  this  fact  has 
been  thought  to  apply  only  to  infectious  diseases,  in  which  the 
organism  was  known  to  respond  to  disturbances  of  its  vital 
activities  by  the  formation  of  antibodies  (antitoxins).  Abder- 
halden passes  by  the  question  whether  the  antibodies  set  free  by 
the  pernicious  activity  of  bacteria  and  their  metabolic  products 
are  identical  with  the  defensive  ferments.  Personally  I  believe 
it  will  be  shown  that  they  are.  The  results  obtained  by  the 
newer  investigations  make  it  seem  probable  that  every  disease 
produces  its  corresponding  defensive  ferments.  For  this  reason 
all  pathology,  all  metabolic  infectious  diseases,  all  intoxications, 
as  well  as  many  nervous  and  mental  diseases,  have  been  placed  in 
a  new  light  as  a  result  of  Abderhalden 's  discovery.  Moreover, 
there  can  no  longer  be  any  doubt  that  the  psychoses  are  not  dis- 


94       THE  UNSOUND  MIND  AND  THE  LAW 

eases  of  a  particular  kind,  but  are  actual  physical  disorders 
which  are  associated  with  material  changes.  Were  this  not  so, 
were  we  obliged  to  assume  that  the  disorders  of  mental  activity 
are  not,  as  are  the  disorders  of  bodily  activity,  anchored  to 
material  substrata,  then  the  finding  in  the  blood  of  the  insane  of 
specific  defensive  ferments,  indicating  changes  in  the  brain 
cortex  and  in  other  organs,  would  be  incomprehensible. 

These  defensive  ferments  are  present  even  at  a  time  when  ap- 
preciable symptoms  of  mental  disorder  are  entirely  missing,  or 
when  the  changes  in  the  brain  cortex,  in  the  thyroid  gland  or  in 
other  organs  that  are  in  any  way  connected  with  psychic  activ- 
ity, are  yet  undiscoverable  by  means  of  any  known  psychiatric 
diagnostic  method.  While  we  have  no  definite  knowledge  of  the 
nature  of  these  defensive  ferments,  as  I  have  already  said,  we 
can  differentiate  them  from  one  another  most  accurately  by 
means  of  their  effects.  There  are  just  as  many  kinds  of  de- 
fensive ferments  as  there  are  pathological  processes. 

The  blood  serum  of  a  cancerous  patient  through  its  specific 
defensive  ferments  acts  differently  from  that  of  a  tuberculous 
patient,  the  blood  serum  of  a  paretic  different  from  that  of  an 
epileptic,  etc.  The  basis  for  this  difference  is  explained  by 
Abderhalden  in  the  following  manner.  The  defensive  ferments, 
like  bacteria,  are  very  fastidious  in  regard  to  their  nourishment 
and  reject  all  nutriment  that  is  foreign  to  their  kind.  The  dif- 
ficulty surrounding  an  artificial  cultivation  of  micro-organisms 
is  due  to  this  fact.  As  is  well  known  to  every  bacteriologist,  the 
lack  of  any  substance  necessary  to  the  development  of  the  bac- 
teria in  the  artificial  culture  medium,  or  any  other  fault  in  the 
composition  of  the  nourishment  which  renders  it  inacceptable 
to  them,  will  cause  them  to  decline  and  perish.  The  defensive 
ferments,  which  are  also  to  be  looked  upon  as  living  cells,  act 
in  a  precisely  similar  manner.  Where  the  nutritive  material  is 
not  adapted  to  their  specific  requirements,  they  do  not  attack  it. 
The  defensive  ferments  always  utilize  for  their  nutrition  only 
those  organs  of  the  body  whose  functions  are  disordered,  for  it  is 
precisely  this  disorder  of  function  which  sets  the  defensive  fer- 
ments free.  In  the  female  organism,  for  example,  there  can 
never  arise  defensive  ferments  against  a  dysfunction  of  the 
testicles  or  in  the  male  body  defensive  ferments  against  a  dys- 
function of  the  ovaries.     If  in  dementia  prascox  occurring  in 


MENTAL  DISORDER  AND  RESPONSIBILITY     95 

female  patients  the  blood  serum  is  brought  into  contact  with 
testicular  substance,  the  latter  remains  unaltered,  just  as 
ovarian  substance  remains  unchanged  when  it  is  mixed  with 
blood  serum  of  male  individuals.  On  the  other  hand,  in  dementia 
praecox  of  female  patients,  ovarial  substance,  and  in  dementia 
prsecox  of  male  patients,  testicular  substance,  are  reduced  in 
each  case,  and  the  substance,  separated  into  its  elementary  com- 
ponents, is  used  as  nourishment.  The  reason  for  this  is  entirely 
clear.  In  the  one  instance  it  is  the  disorder  of  ovarial  function, 
in  the  other  the  disorder  of  testicular  function,  which  has  at  the 
same  time  damaged  the  brain  and  provoked  the  formation  of  the 
defensive  ferments.  The  proof  that  the  brain  has  been  damaged 
by  a  dysfunction  of  the  germinal  glands  is  furnished  by  the  fact 
that  in  every  case  brain  cortex  becomes  reduced  by  the  blood 
serum  of  patients  afflicted  with  dementia  prascox.  This  one 
example  should  give  us  some  notion  how  the  specific  effect  and 
the  mode  of  action  of  each  single  defensive  ferment  can  be  ex- 
plained. The  blood  serum  of  cancer  patients  reduces  carcinom- 
atous tissue,  that  of  goiterous  patients  thyroid  substance,  that 
of  pregnant  women  placental  cells  or  chorionic  epithelia,  etc. 
A.s  the  dysfunction  of  an  organ,  for  instance,  the  thyroid  gland, 
may  manifest  itself,  however,  by  the  production  of  various  forms 
of  disease  (Morbus  Basedowii,  myxcedema,  etc.)  the  positive 
reaction  to  thyroid  gland  alone  would  not  yet  warrant  reliable 
conclusions  concerning  the  specific  character  of  the  defensive 
ferment  and  the  pathological  process  that  is  in  question.  We 
should  bear  in  mind,  however,  that  in  no  pathological  process 
can  there  be  a  question  of  only  one  cause,  of  only  one  disorder 
of  function,  of  only  one  organ  which  has  become  chemically  and 
morphologically  altered,  but  that  in  every  such  process  various 
factors  cooperate  and  various  organs  are  involved. 

All  organs,  as  I  have  already  emphasized,  bear  a  reciprocal 
relationship  to  each  other  through  the  internal  secretions,  and 
are  also  closely  connected  among  themselves  through  the  nervous 
system  and  circulation.  If,  for  instance,  the  thyroid  gland  has 
become  functionally  impotent  or  has  been  operatively  removed, 
other  organs  (brain,  etc.)  which  are  dependent  for  certain 
functions  upon  the  glandula  thyreoidea  will  be  associatively  in- 
capacitated ;  failure  of  these  organs  will  in  turn  be  followed  by  a 
failure  in  other  organs  which  up  to  that  time  they  had  provided 


96   THE  UNSOUND  MIND  AND  THE  LAW 

with  secretion,  etc.  Thus  functional  disturbances  of  a  single 
organ  may  directly  or  indirectly,  chemically  or  morphologically, 
cause  disturbances  of  an  entire  series  of  other  organs  and  pro- 
duce disordered  equilibrium  of  all  vital  activities.  For  the  same 
reason  the  other  organs  which  have  become  involved  by  the 
pathological  process  must  react  specifically  to  the  test  with  de- 
fensive ferments.  If  a  patient's  blood  serum  is  brought  into 
contact  successively  with  the  substances  of  various  organs  ex- 
perimentally offered  as  food  to  the  defensive  ferments,  it  will 
in  one  instance  remain  unchanged,  thus  showing  that  it  pos- 
sesses no  chemical  affinity  for  the  defensive  ferments  and  that 
the  corresponding  organ,  therefore,  has  no  connection  with  the 
pathological  process,  while  in  another  case  the  reaction  will  be  a 
positive  one — that  is,  the  substance  will  be  attacked  by  the  de- 
fensive ferments  contained  in  the  blood  serum,  will  be  disinte- 
grated into  its  elementary  components  and  built  up  into  other 
connections.  This  permits  the  conclusion  that  these  substances 
constitute  the  proper  nutriment  for  the  defensive  ferments  and, 
therefore,  the  function  of  the  organ  from  which  the  substance 
has  been  taken  is  identified  as  the  disordered  one.  In  any  con- 
crete case,  then,  these  organs  which  have  given  a  positive  reaction 
to  defensive  ferments  are  the  ones  which  are  affected  by  the 
pathological  process,  while  the  others  which  have  reacted  nega- 
tively to  the  test  are  not  implicated.  When  to  this  we  add  a 
proper  consideration  of  the  clinical  symptoms,  all  doubt  as  to 
the  nature  of  the  process  should  disappear. 

This  serum  test  for  bodily  disease  is  entirely  applicable  to  the 
psychoses.  It  is  stated  that  of  the  65,000  patients  admitted  an- 
nually into  the  hospitals  for  the  insane  in  the  United  States,  only 
ten  per  cent  belong  to  that  group  clinically  designated  as  a 
general  paresis,  while  twenty  per  cent  of  the  admissions  belong 
to  the  dementia  pragcox  group.  It  is  for  this  large  group  par- 
ticularly that  we  now  possess  a  serologic  test.  The  recent  inves- 
tigations of  Wegener,  three  thousand  experiments  upon  six  hun- 
dred patients,  have  shown  that  by  this  test  we  are  able  definitely 
to  differentiate  the  dementia  prascox  cases  from  those  of  manic 
depressive  insanity  and  hysteria.  Psychopathic  disposition  in 
the  future  as  in  the  past  will  have  to  be  determined,  of  course, 
from  the  family  history  and  from  other  indications,  for  in  itself 
a  disposition  to  disease  is  no  pathological  state  and,  therefore, 


MENTAL  DISORDER  AND  RESPONSIBILITY     97 

cannot  give  rise  to  the  production  of  defensive  ferments. 
"Functional"  or  "psychogenic"  psychoses  and  neuroses  may, 
since  the  discovery  of  the  defensive  ferments,  be  expected  to 
decrease  steadily  in  number  and  significance.  This,  in  other 
words,  signifies  that  we  will  by  means  of  the  Abderhalden  serum 
test  disclose  more  and  more  chemical  and  morphological  changes 
of  cell  structure  in  the  brain  and  other  organs,  so  that  the  purely 
functional  disorders  will  grow  steadily  less  important. 

The  employment  of  Abderhalden 's  sero-diagnosis  in  the  recog- 
nition of  psychoses  again  proves  that  the  disorders  of  mental 
activity  are  essentially  disorders  of  physical  activity,  of  cell 
metabolism  in  the  brain,  of  internal  secretion,  etc.  Wherever 
the  presence  of  defensive  ferments  can  be  demonstrated,  some 
functional  or  organic  disorder  must  exist.  "Where  no  such  de- 
fensive ferments  can  be  discovered  the  disorder  must  be  either 
purely  psychogenic  or  it  may  be  a  simulated  one. 

The  differentiation  hitherto  upheld  of  status  somaticus  and 
status  psychicus  can  actually  no  longer  be  maintained.  The 
psychic  processes  of  life  take  their  course  under  normal  as  well 
as  under  pathological  conditions  according  to  the  same  laws  as 
those  which  govern  physical  processes,  and  in  this  consideration 
of  the  defensive  ferments  I  have  found  a  stimulus  for  again 
laying  stress  upon  this  psycho-physical  parallelism. 


VI 
THE  EXAMINATION  OF  THE  INSANE 

The  examination  of  an  insane  patient  may  be  divided  into 
three  separate  procedures,  that  of  obtaining  the  previous  history 
(anamnesis),  that  of  determining  the  existence  of  bodily  devia- 
tions and  that  of  testing  the  psychic  functions.  The  method  of 
examination  will  necessarily  vary  in  accordance  with  its  purpose, 
and  the  examination  conducted  for  purely  scientific  reasons  will 
not  be  the  same  as  the  one  instituted  essentially  for  the  purpose 
of  determining  an  individual's  sanity  or  insanity.  A  forensic 
report  upon  the  mental  state  of  an  individual  can  never  have  as 
its  aim  the  exposure  of  new  psychiatric  facts,  and  for  this  reason 
all  experimental  study  of  the  individual  under  examination 
should  be  inadmissible.  The  task  of  the  forensic  expert  in  a 
questionable  case  is  always  confined  to  the  practical  purpose  of 
disclosing,  by  means  of  generally  recognized  methods,  the  exist- 
ence either  of  complete  mental  health  and  responsibility,  or  of 
pronounced  mental  disease  with  total  abolition  of  responsibility. 

"Questionable"  cases  are  usually  those  borderland  conditions 
in  which  the  mental  disorder  remains  unrecognized  by  the  gen- 
eral observer,  or  in  which  at  most  there  is  a  question  of  re- 
stricted freedom  of  determination.  In  this  connection,  however, 
the  most  extraordinary  errors  may  take  place.  Thus  in  two 
instances  in  which  I  was  interested,  the  patients,  both  accused 
of  murder,  had  pursued  their  vocations  uninterruptedly  up  to 
the  time  of  the  commission  of  their  deed — yes,  even  until  some 
time  later  when  arrest  followed — and  in  no  way  had  either  one 
aroused  suspicion  among  his  business  associates,  friends  or  ac- 
quaintances that  anything  might  be  wrong  with  him.  Each  of 
these  men  had  carefully  planned  his  crime  in  all  its  details. 
Each  had  taken  measures  to  conceal  his  identity  as  the  per- 
petrator. The  dominant  fact  in  both  cases  was  apparent  mental 
health  and  not  mental  disease,  yet  both  men  were  paranoiacs, 
each  believed  himself  ordained  to  commit  the  murder,  each  had 

98 


THE  EXAMINATION  OF  THE  INSANE       99 

a  bad  family  history,  and  each  in  his  writings  gave  evidence  of 
long  continued  existence  of  the  mental  disease  prior  to  the  com- 
mission of  the  deed. 

Not  many  decades  ago  it  would  have  been  most  difficult  in 
instances  of  this  kind  to  convince  a  judge  that  we  were  dealing 
at  least  with  borderland  cases,  to  say  nothing  of  their  being  un- 
questionable psychoses  of  the  most  dangerous  kind.  Even  at  the 
present  time  the  psychiatric  expert  will  find  himself  confronted 
by  objections  similar  to  those  which  for  decades  and  centuries 
stood  in  the  way  of  a  general  acceptance  of  what  later  became 
manifest  truths;  and  not  only  judges  and  laymen,  but  even 
physicians  seem  to  believe  that  no  mental  disease  exists  which 
does  not  manifest  itself  by  accentuated  symptoms.  This  is  pre- 
cisely the  point  that  distinguishes  the  psychiatric  expert  from 
others  who  believe  themselves  qualified  to  judge  abnormal  mental 
states.  The  person  who  is  not  an  expert  bases  his  opinion  on 
what  he  sees  with  his  own  eyes,  but  the  expert  recognizes  the 
signs  that  are  hidden  from  view.  His  eye  does  not  remain  fixed 
upon  the  surface,  seeing  only  outer  manifestations,  but  he  looks 
deeper  for  the  secret  causes  of  apparently  inexplicable  actions. 
The  thoroughly  diseased  state  of  the  individuals  of  whom  we 
have  just  spoken,  for  instance,  was  revealed  only  through  their 
writings,  in  which  they  gave  expression  to  their  innermost 
thoughts.  From  this  and  similar  experiences  the  following  de- 
ductions may  be  drawn : 

First,  that  a  mental  state  which  the  layman,  on  account  of  the 
apparent  absence  of  intellectual  disorder,  will  consider  a  per- 
fectly normal  one,  or  at  most  a  borderland  condition,  may  be 
revealed  by  the  most  careful  observation  of  a  psychiatrist  as  a 
case  of  pronounced  disease. 

Second,  that  it  is  possible  to  conceal  the  products  of  abnormal 
mental  activity  from  one's  surroundings  and,  hence,  that  it  is 
also  possible  to  make  one's  surroundings  believe  in  the  actuality 
of  a  psychosis  that  does  not  really  exist.  Under  the  searching 
examination  of  the  psychiatrist,  however,  neither  simulation  nor 
dissimulation  can  be  maintained.  A  man  who  has  been  guilty  of 
a  punishable  act  and  is  seeking,  through  simulation  of  mental 
disease,  to  evade  the  consequence  of  his  deed,  may  very  well 
simulate  single  symptoms,  but  he  cannot  feign  the  entire  picture 
of  disease.     All  symptoms  must  be  made  to  harmonize,  but  it  is 


100     THE  UNSOUND  MIND  AND  THE  LAW 

very  difficult  to  do  this  for  any  length  of  time,  no  matter  how 
adept  the  simulator  may  be.  Some  one  time  he  will  forget  him- 
self, will  omit  one  symptom  or  another.  In  order  that  the  pic- 
ture of  disease  be  uniform  and  natural,  the  disease  itself  must 
exist.  But  it  is  equally  difficult  to  succeed  in  the  dissimulation 
of  existing  disease,  such  as  a  chronic  alcoholic  or  squanderer 
might  attempt  in  order  to  evade  a  guardianship.  Simulants  and 
dissimulants  may  deceive  the  layman,  but  not  the  experienced 
psychiatrist.  To  expose  the  attempted  deception,  it  is  not  really 
necessary  to  rely  upon  the  awkwardness  and  forgetfulness  of 
the  actor,  for  other  measures  are  at  our  disposal.  Recurring 
again  to  the  cases  mentioned  above,  it  was  simply  because  the 
individuals  in  question  did  not  happen  to  come  into  close  contact 
with  any  psychiatrist  that  they  were  able,  notwithstanding  the 
existence  of  severe  mental  disorder,  to  carry  on  their  work  for 
many  years  without  creating  any  suspicion  of  insanity. 

In  the  same  connection,  let  it  also  be  stated  that  the  mere 
assertion  of  an  accused  that  he  has  feigned  insanity  is  by  no 
means  sufficient  of  itself  to  justify  a  court  in  declaring  him 
sane  and  criminally  responsible.  It  is  not  uncommon  for  an 
insane  person,  on  finding  that  his  acquittal  on  account  of  mental 
disorder  will  entail  a  longer  period  of  confinement  than  would 
a  conviction  for  the  crime  of  which  he  stands  accused,  to  declare 
he  has  feigned  the  symptoms  of  insanity. 

The  third  lesson  that  may  be  deduced  from  the  two  foregoing 
cases  has  reference  to  the  anamnesis.  It  is  very  exceptional  for 
a  well  defined  psychosis  suddenly  to  appear  in  a  previously  men- 
tally healthy  person.  Usually  the  mental  disorder  develops 
slowly  and  insidiously  upon  the  basis  of  a  congenitally  impaired 
nervous  system.  Neither  the  one  nor  the  other  of  the  two  men 
referred  to  perpetrated  his  crime  in  a  sudden  accession  of  mental 
disorder.  On  the  contrary,  each  of  them  had  for  a  long  period 
of  time  been  ready  for  the  perpetration  of  any  deed  of  violence, 
only  a  slight  initiative  being  required  to  produce  the  actual  out- 
break. It  is,  therefore,  of  the  greatest  importance  that  the 
private  history  of  the  accused  in  all  its  details  should  be  known 
in  every  case  of  mental  disorder,  but  more  particularly  in  every 
forensic  case,  in  which  it  may  be  a  question  not  only  of  a  per- 
son's honor  and  liberty,  but  even  of  his  life. 

Let  me  here  emphasize  the  fact  that  until  a  person  accused  or 


THE  EXAMINATION  OF  THE  INSANE      101 

convicted  of  any  crime  has  been  subjected  to  a  careful  observa- 
tion by  a  psychiatrist,  we  can  never  be  certain  whether  he  is 
mentally  healthy  or  insane.  In  this  connection  I  need  but  recall 
various  recent  occurrences  in  which,  as  a  result  of  their  own 
confessions,  individuals  had  been  sentenced  to  severe  penalties 
and  had  partially  or  entirely  served  their  sentence  before  it  could 
be  demonstrated  that  the  crime  either  had  not  occurred  at  all  or 
had  been  perpetrated  by  others.  Thus,  according  to  a  report  of 
Heilbronner,  a  tribunal  in  Graz  a  few  years  ago  sentenced  to 
death  a  peasant  who  had  voluntarily  surrendered  himself  to  the 
authorities  with  the  declaration  that  he  had  rid  himself  of  his 
idiotic  daughter  by  throwing  her  into  a  rapidly  flowing  stream. 
His  conscience  giving  him  no  rest,  he  said,  he  desired  to  make 
expiation  for  his  crime.  A  prolonged  and  careful  search  for  the 
girl  proved  fruitless.  Although  the  death  sentence  was  pro- 
nounced, it  was  later  commuted  to  imprisonment  for  life.  One 
day  the  missing  girl  reappeared  at  her  home,  having  wandered 
about  as  a  beggar,  unrecognized,  in  the  surrounding  valleys. 
Meanwhile  the  father  had  developed  a  hallucinatory  psychosis 
on  account  of  which  he  was  transferred  from  the  prison  to  an 
asylum.  Upon  the  girl's  return  it  became  manifest  that  this 
hallucinatory  insanity  could  not  be  looked  upon  as  a  prison 
psychosis,  but  that  it  had  already  existed  at  the  time  the  man 
had  surrendered  himself  to  the  authorities.  Had  this  self- 
accused  pseudo-murderer  given  the  slightest  indication  of  an  im- 
pairment of  mental  health,  had  his  self -accusations  been  accom- 
panied by  any  confusion  of  manner,  the  examining  magistrate 
probably  would  have  insisted  upon  an  examination  of  the  man's 
mental  condition.  Partly  from  the  man's  previous  life,  partly 
from  the  mental  and  physical  examination,  a  psychiatrist  would 
undoubtedly  have  been  able  to  determine  that  the  prisoner's 
statements  to  the  court  represented  false  self-accusations  of  a 
kind  not  infrequent  in  hallucinatory  patients,  and  that,  there- 
fore, the  girl 's  disappearance  would  have  to  be  explained  in  some 
other  manner.  Similar  self-accusations  are  frequent  in  melan- 
cholia. Our  police  records  are  full  also  of  ''confessions"  which, 
upon  investigation,  prove  to  have  emanated  from  persons  suffer- 
ing from  hysteria,  from  constitutional  inferiority  or  from  a 
paranoid  mental  disorder. 

In  forensic  practice  it  is  quite  immaterial  whether  the  accused 


102     THE  UNSOUND  MIND  AND  THE  LAW 

makes  the  impression  of  being  mentally  healthy  or  mentally 
sick ;  whether  he  makes  a  confession  or  not,  the  possibility  always 
exists  that  he  may  have  acted  under  the  stress  of  a  pathological 
motive.  As  a  matter  of  principle  it  should  always  be  borne  in 
mind  that  no  person  who  is  accused  of  a  crime  can  a  priori  be 
considered  unquestionably  mentally  healthy  and  responsible. 
Particularly  in  all  such  cases  should  the  psychiatric  expert  who 
is  called  upon  to  test  the  mental  condition  most  carefully  ascer- 
tain all  the  facts  concerning  the  family  history  and  the  previous 
life  of  the  accused,  for  very  often  it  is  precisely  there  that  the 
key  to  an  understanding  of  that  person's  individuality  will  be 
found. 

A.  Anamnesis.  (Previous  History) 

Confronted  with  the  problem  of  examining  an  insane  patient, 
it  would  be  most  unwise  to  enter  upon  the  task  directly  with  the 
aid  of  stethoscope,  percussion  hammer  and  other  instruments  of 
precision  as  one  would  do  in  the  examination  of  patients  suffer- 
ing from  physical  disease.  It  is  much  better,  before  seeing  the 
patient  at  all,  to  obtain  from  the  relatives  a  previous  history  as 
complete  as  possible.  The  most  important  anamnestic  question 
is  the  one  of  hereditary  taint.  In  endeavoring  to  obtain  in- 
formation upon  this  point,  we  must  not  confine  ourselves  to  gen- 
eral questions  concerning  the  occurrence  of  nervous  and  mental 
disease  in  the  family.  On  the  contrary,  it  is  necessary  to  obtain 
as  precise  statements  as  we  can  regarding  each  individual  ances- 
tor and  relative.  Here  in  America,  on  account  of  the  large  im- 
migration, this  is  often  attended  by  insurmountable  difficulties. 
As  a  rule,  the  second  generation  of  the  offspring  of  immigrants 
has  already  lost  knowledge  of  its  family  history.  But  as  official 
registers  are  kept  in  most  of  the  home  countries  of  these  people, 
much  important  information  may  be  obtained  by  appeal  to  the 
proper  authorities.  Where  the  anamnesis  discloses  the  existence 
of  a  direct  or  indirect  hereditary  taint,  no  effort  should  be  spared 
to  obtain  further  information  by  means  of  private  or  official 
inquiry. 

In  this  manner  the  entire  ancestral  and  blood  relationship  of 
the  patient,  paternal  as  well  as  maternal,  may  be  investigated. 
In   cases  in   which   the   family   history   shows  the   occurrence 


THE  EXAMINATION  OF  THE  INSANE     103 

of  mental  or  nervous  disease  to  be  of  particular  frequency,  the 
preparation  of  an  ancestral  table  or  family  tree,  or  of  an  accu- 
rate genealogical  chart  covering  the  entire  family  from  a  psy- 
chiatric point  of  view,  should  be  undertaken.  Although  it  may 
not  always  be  possible  to  determine  the  form  of  psychosis  with 
which  individual  progenitors  have  been  afflicted,  the  mere  fact 
that  they  have  been  mentally  abnormal  is  worthy  of  special  note. 
As  it  appears  to  me,  so  long  as  we  remain  unable  to  construct  an 
accurate  ancestral  chart  for  each  individual,  the  entire  system 
of  criminology,  the  search  for  the  cause  of  criminality  in  psychic 
degeneration,  will  be  erected  upon  shifting  sand. 

What  previously  had  been  neglected  in  this  regard  can  prob- 
ably never  be  remedied,  but  in  every  country  there  could  hence- 
forth be  established  a  central  office  in  which  the  pertinent  facts 
should  be  gathered  and  classified,  and  to  which  all  cases  of 
mental  disease,  their  causes  (syphilis,  alcoholism,  heredity),  and 
in  event  of  death  the  result  of  the  autopsies  should  be  reported 
by  insane  asylums,  hospitals  and  physicians  in  private  practice. 
Naturally  the  matter  collected  by  such  an  office  should  be  con- 
sidered secret  and  inviolable  and  not  subject  to  public  inspec- 
tion. "Where  an  individual  has  come  into  conflict  with  the  law, 
however,  it  would  be  possible  to  determine  at  once  whether  he  is 
hereditarily  tainted,  whether  he  had  previously  shown  any  signs 
of  abnormal  mentality,  whether  he  had  received  an  injury,  had 
been  syphilitically  infected,  or  was  addicted  to  alcohol,  etc. 
Should  such  data  later  become  part  of  the  court  proceedings,  be 
published  in  the  daily  press  and  thereby  cause  the  antecedents 
of  an  insane  person  to  become  the  subject  of  wanton  gossip,  this 
objectionable  feature  should  be  accepted  as  the  inevitable  price 
we  would  have  to  pay  for  the  advantages  that  would  neverthe- 
less accrue  to  criminalistic  studies.  With  such  as  arrangement 
forensic  psychiatry  would  at  all  times  have  at  its  disposal  the 
data  necessary  for  establishing  a  reliable  anamnestic  basis  in 
every  case,  one  that  would  be  independent  of  the  so  often  un- 
reliable statements  made  by  the  relatives  of  the  patients  and  by 
the  patients  themselves.  The  true  interests  of  a  sick  person  who 
for  one  reason  or  another  has  been  brought  to  the  bar  of  Justice 
require  not  concealment  but  the  disclosure  of  all  the  antecedent 
details  of  his  own  life  and  of  that  of  his  family  that  might  fur- 
nish proof  of  his  psychopathic  taint  and  thus  safeguard  him 


104     THE  UNSOUND  MIND  AND  THE  LAW 

against  unmerited  punishment.  The  greatest  benefit  from  the 
existence  of  such  archives,  destined  solely  for  official  use,  would, 
therefore,  accrue  to  the  patient  himself. 

On  the  other  hand,  the  science  of  criminology  would  benefit 
by  being  taught  the  manner  in  which  the  laws  of  heredity  op- 
erate. As  has  already  been  explained,  the  theory  of  the  Mendelian 
law  of  heredity  has  been  tested  experimentally  upon  plants  and 
animals,  but  has  thus  far  proven  of  little  practical  value  for  the 
human  race,  because  there  have  existed  no  family  trees  the  com- 
parison of  which  would  enable  us  to  draw  definite  trustworthy 
deductions.  A  plant  or  an  animal  can  be  segregated,  its  char- 
acteristics accurately  determined,  and  the  condition  under  which 
it  exists  can  then  be  altered  in  any  desired  manner.  It  can  be 
permitted  to  couple  with  other  species  of  its  kind  whose  char- 
acteristics also  have  been  carefully  studied,  and  by  observing 
the  resultant  generation  we  can  determine  which  properties  of 
the  parent  have  been  and  which  ones  have  not  been  transmitted. 
This  procedure  may  be  repeated  under  varying  conditions 
through  any  number  of  generations  and  thus  we  can  note  which 
traits  remain  constant,  which  ones  disappear  entirely  and  which 
ones  skip  certain  generations  in  order  to  appear  anew  in  others. 
By  this  means  it  can  be  definitely  determined  that  a  generation 
with  certain  traits  is  the  product  of  definite  factors.  In  man, 
however,  such  experiments,  which  should  be  conducted  into  the 
fifth  and  sixth  generation,  are  of  course  impossible.  Animals 
and  plants  may  be  coerced  to  live  and  propagate  under  artificial 
experimental  conditions.  Not  so  human  beings.  In  our  study 
of  man  we  are  limited  to  the  observation  and  registration  of  his 
specific  traits  and  to  a  notation  of  the  conditions  under  which 
these  traits  become  changed  in  the  offspring. 

In  relation  to  psychoses  a  distinction  must  be  made  between 
direct,  atavistic,  collateral  and  cumulative  heredity.  Direct  in- 
heritance exists  when  father  or  mother  has  been  afflicted  with 
insanity ;  atavistic  heredity  when  the  grandparents  have  been  so 
affected ;  collateral  heredity  when  relatives  from  side  branches 
(uncles,  aunts,  cousins,  etc.)  have  been  affected,  and  cumulative 
heredity  when  father  as  well  as  mother  has  been  affected.  There 
exists  also  a  form  of  heredity  known  as  progressive  (Morel)  that 
consists  in  an  augmentation  of  the  severity  of  the  psychosis  as 
it  occurs  in  certain  of  the  hereditarily  tainted  individuals,  until 


THE  EXAMINATION  OF  THE  INSANE     105 

finally  feeblemindedness  and  idiocy  cause  an  extermination  of 
the  family. 

The  question  of  the  import  of  the  various  forms  of  hereditary 
taint  has  given  rise  to  much  discussion,  and  it  is  now  accepted 
that  indirect  heredity  in  the  absence  of  direct  transmission  is  of 
only  minor  importance  in  the  production  of  insanity.  The  fac- 
tors that  are  to  be  considered  important  for  the  transmission  of 
an  hereditary  taint  are  above  all  mental  disorder,  alcoholism, 
suicide,  nervous  diseases  and  syphilis  in  the  ascendants.  Tuber- 
culosis and  diabetes  are  not  without  influence.  A  consideration 
of  these  hereditary  factors  shows  that  about  75  per  cent  of  all 
insane  are  thus  predisposed,  while  upon  the  other  hand  we  have 
also  learned  that  50  per  cent  of  all  hereditarily  tainted  individ- 
uals remain  mentally  healthy.  For  this  reason  family  charts 
alone  offer  no  proof  of  the  inheritance  of  insanity;  and  unless 
taken  in  conjunction  with  the  individual's  environment  and  de- 
velopmental history  they  prove  nothing,  no  matter  how  somber 
they  may  appear.  Nevertheless  it  must  be  evident  that  the  es- 
tablishment of  special  state  archives  for  the  purpose  of  register- 
ing the  mental  and  physical  status  of  every  individual  with 
special  reference  to  his  criminal  tendencies  would  in  a  few 
years  be  of  the  greatest  benefit  to  psychiatry  as  well  as  to  crim- 
inology. With  such  archives  at  our  disposal,  the  previous  his- 
tory of  any  given  case  could  be  constructed  simply  by  a  proper 
arrangement  of  the  relative  facts. 

For  every  study  of  a  family  history  the  following  points  merit 
special  attention :  Consanguinity  and  marked  differences  in  the 
ages  of  the  parents;  character,  temperament  and  proclivities  of 
father  and  mother;  mental  or  nervous  diseases  of  the  parents; 
constitutional  diseases  of  the  parents  (tuberculosis,  syphilis, 
gout,  diabetes,  etc.)  ;  alcoholism  in  the  parents;  suicide  or  at- 
tempted suicide  on  the  part  of  the  father  or  mother;  criminal 
acts  of  father  or  mother;  convulsions  in  the  father  or  mother. 

The  investigation  of  these  points  should  be  extended  so  as  to 
include  the  grandparents  and  great-grandparents,  as  well  as 
collateral  relatives.  Furthermore,  we  should  endeavor  to  ascer- 
tain whether  cases  of  congenital  malformation,  blindness,  deaf- 
ness or  deaf-mutism  have  occurred  in  the  family,  whether 
brothers  and  sisters  of  the  patient  are  normal  and  whether  any 
have  died  in  infancy  and,  if  so,  of  what  disease.     After  having 


106     THE  UNSOUND  MIND  AND  THE  LAW 

thus  obtained  a  clear  picture  of  the  entire  family  tree  and  con- 
structed a  genealogical  register,  and  after  having  ascertained 
particularly  whether  such  or  similar  psychoses  have  occurred  in 
the  antecedents,  and  whether  for  that  reason  a  hereditary  taint, 
even  if  only  in  the  form  of  general  inferiority  of  the  brain  and 
nervous  system,  may  be  assumed  to  exist,  we  proceed  to  the  in- 
vestigations of  the  previous  history  of  the  patient  up  to  the  time 
that  the  disease  itself  became  manifest.  This  investigation  must 
embrace  the  entire  mental  and  physical  development  prior  to  the 
occurrence  of  the  psychosis. 

It  will  be  well  for  the  psychiatric  expert  to  maintain  a  certain 
sequence  in  the  questions  asked  regarding  the  previous  history 
of  a  case  under  investigation.  He  should  first  determine 
whether  the  patient  has  had  any  convulsions  in  childhood,  and 
if  so,  when  and  for  how  long  a  time,  or  whether  he  had  been  af- 
fected with  rhachitis  or  other  diseases.  In  this  connection  we 
may  also  learn  at  what  age  the  patient  began  to  walk  and  to 
speak.  Next  the  patient's  psychic  comportment  at  school  should 
be  investigated.  We  will  ascertain  whether  he  learned  easily  or 
with  difficulty,  whether  he  showed  any  one-sided  talents  or  de- 
veloped particularly  early  and  what  were  his  relations  to  his 
associates  in  school.  It  will  be  very  important  to  ascertain 
whether  the  patient  changed  his  pursuits  frequently,  and  if  so, 
for  what  reason,  and  whether  he  was  efficient  in  his  various  posi- 
tions. Finally,  we  should  ascertain  whether  the  patient  had 
ever  received  any  injury  to  his  head,  whether  he  had  been  ad- 
dicted to  the  use  of  alcohol  or  committed  sexual  excesses,  whether 
he  had  suffered  from  syphilis  or  other  bodily  diseases,  whether, 
if  married,  his  marriage  had  been  a  happy  one,  whether  he  has 
children,  and  if  so,  how  many  and  whether  they  are  healthy. 

All  these  questions  are  essential  in  order  that  a  picture  may 
be  obtained  of  the  patient  as  he  was  before  he  became  mentally 
disordered.  As  I  have  already  explained,  the  essence  of  every 
psychosis  is  an  alteration  of  personality.  Only  by  a  comparison 
of  the  former  and  the  present  mental  state  can  an  opinion  be 
obtained  regarding  the  alteration  in  personality  that  may  have 
taken  place,  and  regarding  the  severity  of  the  disease.  For  this 
reason  it  is  extremely  important  to  know  all  the  details  of  the 
patient's  previous  life,  of  the  surroundings  among  which  he 
grew  up  and  of  his  antecedents.     Having  obtained  a  clear  un- 


THE  EXAMINATION  OF  THE  INSANE     107 

derstanding  of  the  previous  personality  of  the  patient,  of  the 
joys  and  sufferings  of  his  life,  the  psychiatrist  proceeds  to  an 
investigation  regarding  the  commencement  and  the  course  of 
the  disease.  The  physician  should  know  whether  the  onset  of 
the  disease  occurred  gradually  or  suddenly,  whether  it  followed 
an  injury  or  severe  emotional  shock,  etc.,  and  whether  the 
change  in  character  took  place  correspondingly  slowly  or 
rapidly. 

There  are  many  insane  who  present  pathological  traits  only 
in  their  relationship  to  their  families  and  to  society,  but  whose 
bearing  when  by  themselves  hardly  gives  the  impression  that 
they  are  abnormal.  Many  decidedly  inferior  individuals  appear 
entirely  normal  so  long  as  they  are  free  from  serious  obligations, 
from  worry  on  account  of  a  large  family,  from  exhausting  and 
responsible  work,  etc.  Hence  in  them  the  alteration  of  char- 
acter manifests  itself  far  more  abruptly  when  they  are  exposed 
to  the  latter  conditions.  We  should  furthermore  note  whether 
and  to  what  extent  the  patient  suffers  from  sleeplessness.  Just 
as  the  recurrence  of  regular  sleep  is  one  of  the  symptoms  of 
returning  health,  so  disordered  sleep  is  one  of  the  earliest  and 
most  frequent  occurrences  in  the  early  stage  of  insanity. 
Furthermore  we  must  ascertain  from  relatives  or  friends 
whether  the  patient  was  in  the  habit  of  conversing  with  himself 
or  with  persons  who  were  absent,  of  listening  or  staring  fixedly 
in  one  direction,  of  searching  through  the  rooms  and  furniture 
in  the  house  or  by  other  noticeable  actions  creating  the  impres- 
sion that  he  suffered  from  sense  deceptions.  Moreover  we  must 
ascertain  whether  he  had  given  evidence  of  delusions,  whether 
he  believed  himself  to  be  followed  or  persecuted,  whether  he  sud- 
denly believed  himself  to  be  a  powerful  personage,  etc.  Under 
the  influence  of  ideas  of  grandeur  a  modest  person  will  become 
transformed  into  a  boastful  one,  an  economical  person  becomes 
extravagant,  a  timid  one  intrepid.  Notions  of  self-depreciation 
make  a  miser  of  the  prodigal  and  a  coward  of  the  courageous. 
A  man  hitherto  studiously  attentive  to  his  outward  appearance 
becomes  careless  of  his  body  and  clothes.  A  loquacious  man 
becomes  reticent,  one  of  a  joyous  temperament  becomes  de- 
pressed. The  information  obtained  by  means  of  these  questions 
enables  the  examiner  to  obtain  a  fairly  accurate  picture  of  the 
development  of  the  disease  even  before  he  has  actually  seen  the 


108     THE  UNSOUND  MIND  AND  THE  LAW 

patient.  The  information  that  the  emotional  change  in  a  patient 
has  occurred  more  or  less  suddenly,  that  without  apparent  cause 
the  patient's  mood  has  changed  from  one  of  abnormal  joyousness 
into  one  of  angry  excitement  or  disinterested  apathy,  that  the 
patient  has  refused  to  take  nourishment,  has  become  violent,  has 
made  an  attempt  at  suicide,  has  suffered  any  marked  loss  of  in- 
telligence and  memory,  will  particularly  tend  to  give  a  special 
impress  to  the  suspicion  of  an  existing  psychosis. 

When  the  physician  has  logically  associated  the  patient's  fam- 
ily history,  the  nature  of  an  existing  hereditary  taint,  the  pa- 
tient's previous  life,  the  characteristic  manifestations  of  an 
alteration  of  personality,  the  deleterious  influences  to  which  the 
patient  has  been  exposed  and  which  have  culminated  in  the  pro- 
duction of  the  psychosis,  he  will  in  many  cases  be  able  from  the 
anamnesis  alone  to  make  a  probable  diagnosis.  Nevertheless  it 
would  of  course  be  most  inadmissible  to  rely  implicitly  upon 
the  statements  of  relatives  and  friends ;  an  erroneous  interpreta- 
tion of  the  person 's  psychic  comportment,  undue  stress  laid  upon 
certain  symptoms,  the  non-observance  of  certain  others,  would 
easily  make  the  previous  history  appear  different  from  what  it 
really  is.  As  in  all  other  diseases,  so  here  the  physician  must 
himself  see  the  patient,  question  him  and  examine  him  physically 
and  psychically.  What  the  physician  has  been  told  about  the 
patient,  or  what  the  patient  himself  states,  can  never  be  de- 
terminative for  a  diagnosis.  For  this  purpose  the  objective  find- 
ings alone  will  be  conclusive. 

B.  Observation  of  the  Patient 

Before  commencing  an  examination  of  a  patient,  the  physician 
should  always  state  the  purpose  of  his  visit.  Particularly  in  the 
case  of  refractory  patients  it  is  well  not  to  conceal  the  object 
for  which  one  has  come.  The  physician  should  state  to  the 
patient  that  he  has  been  requested  to  examine  him  and  that  he 
will  have  no  difficulty  in  determining  his  actual  condition.  If 
he  is  sick  he  is  to  receive  care  and  treatment;  if  he  is  in  good 
health  a  report  to  that  effect  will  be  made.  Never  in  such  an 
examination  should  the  physician  forget  that  he  is  dealing  with 
a  living  human  being,  with  one  who  is  mentally  abnormal,  often 
irritable,  sensitive,  suspicious  and  apprehensive,  and  one  who 


THE  EXAMINATION  OF  THE  INSANE     109 

will  immediately  become  excited,  depressed  or  intimidated  by 
aggressive  questioning.  Some  insane  persons  have  a  just  appre- 
ciation of  their  condition  and  know  they  are  sick.  Others  lack 
this  insight  and  believe  themselves  to  be  healthy.  Possibly  they 
have  heard  of  an  undesirable  member  of  a  family  being  placed 
in  an  institution  by  unscrupulous  relatives  and  for  that  reason 
they  believe  they  themselves  are  to  be  deprived  irrevocably  of 
their  liberty.  The  suspicion  with  which  such  patients  will  re- 
ceive a  physician  is  therefore  quite  natural.  Nevertheless  the 
physician  must  not  conceal  from  them  the  object  of  his  visit. 

The  reception  that  a  patient  gives  a  physician  is  of  itself  often 
characteristic.  "While  the  manic  patient,  who  has  perhaps  never 
before  seen  the  physician,  at  once  greets  and  accosts  him  with 
a  stream  of  words,  the  paranoiac  moodily  or  repellently  turns 
his  back  and  refuses  to  enter  into  any  conversation.  The  melan- 
choliac  is  often  found  lying  despondently  in  bed  and  receives 
the  caller  with  indifference,  while  the  stuporous  or  confused 
patient  pays  no  attention  whatsoever  to  the  physician's  entrance. 

Whether  the  inquiry  into  a  person's  mental  state  should  be 
preceded  by  a  physical  examination  will  depend  upon  the  indi- 
vidual case.  In  some  instances  the  patient  gains  repose  and 
confidence  when  he  observes  that  the  physician  has  first  taken 
note  of  his  general  appearance,  the  condition  of  his  tongue,  the 
state  of  his  pulse,  etc. ;  in  others  the  patient  is  so  opposed  to 
any  examination  that  his  physical  condition  can  be  ascertained 
only  by  means  of  the  general  observation  that  can  be  made  while 
conversing  with  him.  In  the  majority  of  instances,  as  I  have 
already  stated,  it  will  be  better  not  to  begin  the  examination 
with  instruments  of  precision,  stethoscope  and  percussion  ham- 
mer, but  to  obtain  a  general  impression  from  careful  observation, 
carried  out  under  the  guise  of  an  indifferent  conversation.  The 
patient's  physiognomic  expression  should  receive  attention  first. 
In  many  instances  the  experienced  psychiatrist  will  be  able  to 
draw  most  valuable  diagnostic  inference  from  a  study  of  the 
facial  traits  and  from  the  attitude  of  the  body.  Fuhrman  and 
others  have  called  attention  to  the  fact  that  there  is  usually  a 
marked  difference  in  the  mimic  and  physiognomic  means  of 
expression  of  the  insane  and  of  healthy  persons. 

The  facial  expression  of  most  insane  persons  at  once  arouses 
the  suspicion  of  an  existing  psychosis.     Most  forms  of  mental 


110     THE  UNSOUND  MIND  AND  THE  LAW 

disease  are  characterized  by  so  distinctive  a  physiognomy  that 
it  is  almost  possible  to  read  the  diagnosis  from  the  patient's 
face.  In  some  patients,  particularly  in  those  who  will  not  speak, 
and  in  those  who  are  entirely  reaetionless  and  cannot  be  aroused 
from  their  stupor,  the  physiognomy  is  not  infrequently  the  only 
available  clue  to  a  diagnosis. 

The  facial  expression  may  be  sad,  painful,  dejected.  This  is 
the  case  in  melancholia  and  all  states  of  depression.  The  eyes 
are  lustrous  but  tearless,  the  forehead  is  deeply  furrowed  ver- 
tically, or  shows  the  well  known  wrinkles  caused  by  sorrow. 
Usually  all  other  mimic  play  of  features  is  wanting.  The  same 
sorrowful  expression  always  persists.  The  eyes  are  often  cast 
down  and  the  lower  jaw  relaxed  and  pendant.  "Where  the 
melancholiac  is  governed  by  self-accusations  or  by  ideas  of  per- 
secution, his  facial  expression  will  be  tense;  the  staring  eyes 
protrude  from  their  sockets,  are  glistening  and  widely  opened. 
The  median  portions  of  the  eyebrows  are  raised,  the  nostrils 
dilated,  the  naso-labial  furrows  deeply  marked,  the  angles  of 
the  mouth  depressed,  the  facial  traits  masklike,  immovable,  the 
entire  physiognomy,  together  with  the  horizontal  deeply  wrin- 
kled forehead,  represent  the  perfected  expression  of  the  sorrow- 
ful feelings  and  delusions  that  control  the  patient. 

In  mania  the  facial  expression  is  vivacious  and  noticeably 
joyous,  the  forehead  is  usually  smooth,  the  play  of  features 
mobile.  The  eyes  sparkle,  the  skin  at  their  outer  angles  is  laid 
into  minute  folds,  popularly  known  as  "crows'  feet."  The 
mouth  has  a  smiling  expression  and  the  face  is  usually  suffused. 
A  tense,  expectant  facial  expression  is  characteristic  of  all  pa- 
tients having  sense  deceptions.  The  physiognomy  in  paranoia 
is  suspicious,  inimical,  threatening.  Patients  in  this  category 
have  a  shifting,  indirect,  expectant  look.  The  lips  as  a  rule  are 
tightly  compressed.  When  questioned  these  patients  smile  pat- 
ronizingly or  superciliously,  ironically.  The  facial  expression 
in  states  of  ecstasy  is,  as  so  often  seen  in  epilepsy,  blissful  and 
enraptured.  The  glistening,  widely  opened  eyes  are  usually 
turned  upward,  fixed  upon  one  point.  The  patient's  physiog- 
nomy is  usually  a  replica  of  the  entranced  expression  found  in 
the  pictures  of  the  Madonna  and  the  saints. 

In  katatonia,  on  the  other  hand,  the  facial  expression  is 
masklike,  expressionless.    All  facial  folds  are  obliterated.   There 


THE  EXAMINATION  OF  THE  INSANE     111 

is  but  infrequent  winking  of  the  eyelids,  the  patient's  look  is 
distraught,  vacuous  and  expressionless.  Proud,  exalted,  pre- 
sumptuous, often  threatrically  majestic,  is  the  facial  expression 
of  the  patient  who,  dominated  by  delusions  of  grandeur,  believes 
himself  to  be  immensely  rich  or  powerful,  the  head  of  a  nation 
or  the  Maker  of  the  universe.  In  general  paresis,  even  in  the 
beginning,  when  the  psyche  is  relatively  unaffected,  the  relaxed, 
weak,  undecided  facial  expression  attracts  attention.  This  is 
often  associated  with  differences  in  facial  innervation,  asym- 
metry as  a  result  of  unilateral  paralysis  of  the  facial  muscles, 
pupilary  inequality  and  twitchings  in  the  mimic  musculature. 
In  advanced  cases  the  physiognomy  is  apathetically  expres- 
sionless or  reflects  the  puerile  ideas  of  grandeur  or  the  weak- 
minded  euphoria  so  characteristic  of  general  paresis. 

In  the  alcoholic  we  usually  find  the  face  coarse,  sodden  and 
traversed  by  enlarged  and  distended  veins;  while  the  face  of 
the  epileptic  who  is  not  in  a  state  of  ecstasy  often  bears  a  suf- 
fering or  dreamy  expression.  The  epileptic,  moreover,  attracts 
attention  on  account  of  the  frequently  existing  abnormalities  of 
the  skull,  the  thickened  lips,  the  massive  and  inexpressive  fore- 
head and  the  widely  separated  eyes  with  their  peculiar  stupid 
expression. 

In  dementia  the  face  is  less  indicative  of  the  mental  state 
than  it  is  in  the  affections  we  have  already  mentioned.  Often 
it  is  impossible  to  say  what  constitutes  the  characteristic  ex- 
pression of  the  demented  physiognomy.  In  general  the  facial 
expression  of  the  insane  when  dementia  has  once  set  in  is  a 
permanent  one,  reflecting  in  a  modified  manner  the  pathological 
affects  (fear,  sorrow,  suspicion)  which  have  influenced  the  pa- 
tient during  the  acute  stage.  The  play  of  features  is  usually 
most  meager,  the  mouth  half  opened,  the  jaw  relaxed  and  hang- 
ing, with  saliva  dribbling  from  the  mouth.  A  specific  demented 
expression,  one  that  could  be  utilized  for  purposes  of  differential 
diagnosis,  does  not  exist.  Frequently,  notwithstanding  that  a 
patient's  physiognomy  would  lead  one  to  assume  the  existence 
of  a  dementia,  recovery  does  take  place. 

In  most  cases  of  insanity  we  find  that  the  patient's  posture 
and  gestures  accord  with  the  physiognomic  expression.  The 
melancholiac  is  usually  found  sitting  relaxed  and  sunken,  with 
arms  hanging  by  his  side  or  folded  in  his  lap.     The  head  is 


112     THE  UNSOUND  MIND  AND  THE  LAW 

lowered  and  the  entire  posture  expresses  the  existing  hopeless 
sorrow,  the  expressive  consciousness  of  guilt.  Melancholiacs 
move  about  but  little,  or  they  carry  out  monotonous  movements 
which  convey  the  impression  of  nervousness  and  embarrassment ; 
they  bite  their  finger  nails,  jerk  the  bed  coverings  to  and  fro, 
pick  at  the  night  shirt,  etc.  When,  however,  the  state  of  de- 
pression is  associated  with  one  of  fear,  as  it  so  often  is,  melan- 
choliacs may  become  markedly  agitated ;  then  they  sigh,  lament, 
wring  their  hands,  run  planlessly  to  and  fro,  kneel,  run  toward 
the  door,  strike  their  breasts,  tear  their  hair  and  cling  with 
apprehension  to  every  one  who  approaches  them.  Often  they 
are  attacked  by  a  sensation  of  precordial  fear  and  press  their 
hands  convulsively  over  the  region  of  the  heart.  In  cases  of 
most  intense  fear,  there  exists  complete  immobility.  Not  a 
muscle  of  the  face  flickers  to  interrupt  the  expression  of  fear 
and  horror,  not  a  limb  is  moved  until  possibly  a  sudden  im- 
pulsive outbreak  {raptus  melanchoUcus)  annuls  the  patient's 
immobility. 

On  the  other  hand,  the  gestures  and  comportment  of  maniacal 
patients  are  most  disordered.  They  gesticulate  vivaciously,  fre- 
quently assume  theatrical  poses  and  are  in  a  state  of  constant 
movement.  They  run  to  and  fro  without  purpose,  skip,  jump, 
dance,  roll  upon  the  floor. 

In  paretics  we  very  easily  note  the  lack  of  physical  control. 
Even  when  suffering  from  delusions  of  grandeur,  the  uncer- 
tainty of  their  postural  control,  their  tremor  and  swaying,  often 
contrast  with  the  feeling  of  greatness  and  mightiness  that  gov- 
erns them  and  from  which  one  would  expect  the  assumption  of 
a  majestic  bearing.  In  paranoiacs  having  ideas  of  grandeur, 
this  contrast  does  not  exist.  They  assume  a  majestic  pose,  the 
head  is  proudly  lifted,  the  arms  are  waved  in  a  theatrical  man- 
ner, the  gait  is  dignified,  everything  about  such  patients  tends 
to  impress  the  people  around  them.  When,  on  the  other  hand, 
the  paranoiac  suffers  from  delusions  of  persecution,  his  gesticu- 
lations are  reserved  and  restricted.  Then  his  manner  is  for- 
bidding and  often  threatening. 

All  dements  present  one  and  the  same  picture.  Their  bearing 
is  relaxed  and  without  energy,  their  gait  dragging  and  shaky, 
the  head  hangs  forward  upon  the  chest,  and  the  body  is  bent 
as  in  old  age.     Wherever  this  characteristic  posture  is  found, 


THE  EXAMINATION  OF  THE  INSANE     113 

an  incurable  state  may  with  reasonable  certainty  be  diagnosed 
and  prognosticated. 

From  these  descriptions  of  the  expression  and  physiognomy 
of  the  insane,  it  must  be  clear  that  even  a  good  actor  or  a  physi- 
cian who  would  study  and  practice  the  portrayal  of  all  these 
symptoms  for  the  purpose  of  deception  could  hardly  carry  out 
his  role  of  simulator  with  success.  It  is  quite  as  difficult  for  a 
healthy  person  to  feign  insanity  as  it  is  impossible  for  an  insane 
person  to  deceive  an  expert  psychiatrist  for  any  length  of  time 
by  a  simulation  of  mental  health. 

Laymen  and  even  shrewd  jurists  may  be  deceived  by  the  mani- 
festations of  such  simulation  or  dissimulation,  but  the  trained 
psychiatrist  cannot  thus  be  led  astray.  In  the  majority  of  in- 
stances, moreover,  it  is  not  a  question  of  real  simulation  but 
one  of  a  marked  exaggeration  of  symptoms  of  a  disease  that 
actually  exists.  We  know  very  well  that  most  simulants  are 
psychopaths,  who  for  this  very  reason  are  able  all  the  more 
easily  to  play  their  part.  The  judge  as  a  rule  believes  the 
existence  of  mental  disease  to  be  incompatible  with  the  existence 
of  simulation  in  the  same  individual;  the  expert  on  the  other 
hand  knows  that  simulation  is  frequent  in  the  insane.  Some 
of  the  cases  of  supposed  simulation  I  have  had  to  examine  were 
actually  cases  of  dementia  praecox.  Many  cases  of  this  disease, 
with  their  varying  antithetic  symptoms,  do  appear  so  unreal 
to  the  lay  observer  that  errors  of  this  kind  are  not  infrequent. 
If  it  were  possible  after  a  period  of  years  to  reexamine  those 
who  have  been  declared  simulators,  it  would  be  found  that  in 
the  majority  of  instances  the  decision  was  an  error.  A  patient 
who  was  discharged  from  a  criminal  insane  asylum  and  sent 
back  to  prison  on  the  ground  of  simulation,  when  I  saw  him  a 
year  later  proved  to  be  an  accentuated  case  of  dementia  praecox. 

Let  us  now  take  up  the  question  of  the  determination  of  the 
presence  of  sense  deceptions  by  means  of  objective  signs.  This 
of  course  is  of  the  greatest  importance.  Were  the  statement 
of  every  criminal  that  he  had  a  vision,  had  heard  a  voice,  had 
been  commanded  by  God  to  do  this,  that  or  the  other,  to  be 
accepted  without  any  possibility  of  corroboration,  the  examiner 
would  indeed  be  placed  in  an  anomalous  position.  Fortunately, 
however,  such  is  not  the  case.  There  are  numerous  objective 
symptoms  which  must  accord  with  one  another  before  any  one 


114     THE  UNSOUND  MIND  AND  THE  LAW 

of  them  can  be  accepted  as  a  manifestation  of  a  subjective 
happening.  The  individual  traits  of  such  manifestation  may 
well  be  imitated  but  never  can  the  entire  combination  of  parts 
be  copied.  He  who  omits  one  or  another  of  these  component 
parts  or  who  confounds  symptoms  belonging  to  different  classes, 
at  once  reveals  himself  to  the  eye  of  the  trained  psychiatrist 
as  a  simulant. 

The  patient  with  auditory  hallucinations  keeps  his  eyes  closed, 
moves  his  lips  slightly  every  now  and  then,  meanwhile  turning 
his  ear  attentively  in  some  one  direction;  or  else  the  eyes  and 
mouth  are  wide  open,  while  the  head  is  turned  upward  or  side- 
wise,  as  though  the  patient  were  listening  intently.  Often  and 
for  a  long  time  his  respiration  is  very  superficial  or  almost  sup- 
pressed; the  pulse  is  hard,  tense  and  retarded.  As  a  result  of 
the  sense  deceptions,  the  patient  suddenly  begins  to  laugh  or 
to  cry,  or  his  face  assumes  a  threatening  expression  independent 
of  any  appreciable  external  cause.  For  the  recognition  of  audi- 
tory hallucinations  in  the  insane  who  attempt  to  conceal  them 
we  are  dependent  above  all  upon  a  study  of  the  physiognomy. 
When  such  patients,  believing  themselves  unobserved,  place  no 
restraint  upon  their  inner  impulses,  the  sudden  occurrence  of 
an  attitude  of  marked  concentration,  as  though  the  patient  were 
listening  intently,  or  a  quick  inimical  side-glance  or  some  other 
slight  manifestation  will  enable  the  observer  to  recognize  the 
existence  of  auditory  hallucinations.  The  dissimulating  patient, 
also,  should  be  drawn  into  a  prolonged  conversation.  When 
this  is  done  he  will  be  found  to  hesitate  from  time  to  time,  will 
be  distraught,  will  here  and  there  ask  an  inappropriate  question 
and  by  his  facial  demeanor  will  show  that  he  is  not  listening 
to  the  conversation  but  to  some  inner  voice.  Patients  who  are 
particularly  annoyed  by  auditory  hallucinations  will  plug  their 
ears  or  draw  the  bed  covers  over  their  heads  to  rid  themselves 
of  the  voices.  Notwithstanding  these  measures  of  self -protection, 
they  will  suddenly  begin  to  scold,  make  threatening  gestures 
and  thus  demonstrate  that  the  unwelcome  voices  have  again 
been  heard. 

The  existence  of  visual  hallucinations  may  be  recognized  by 
the  widely  opened  eyes,  the  large  pupils  and  the  immobile  stare 
fixed  upon  a  certain  point.  In  accordance  with  the  nature  of 
these  hallucinations,  the  patient's  expression  will  be  that  of  bliss, 


THE  EXAMINATION  OF  THE  INSANE     115 

ecstasy,  fright  or  apprehension.  Sometimes  the  eyes  wander  to 
and  fro  as  though  endeavoring  to  rivet  the  apparently  moving 
but  actually  non-existent  object.  Under  these  circumstances 
the  pupils  will  change  frequently,  contracting  as  the  vision  ap- 
proaches and  dilating  as  it  recedes.  When  in  the  presence  of 
an  alarming  vision  the  patient  will  often  close  the  eyes,  rub 
them  and  shake  himself.  Believing  himself  to  be  attacked  by 
the  visionary  beings,  the  patient  will  call  them  by  vituperative 
names  or  throw  things  at  them.  Patients  in  alcoholic  delirium 
catch  and  kill  the  bugs,  rats  and  mice  that  constitute  part  of 
their  visionary  imagination.  Visions  are  produced  almost  only 
in  those  states  in  which  consciousness  is  more  or  less  obscured, 
as  in  epileptic  twilight  states,  fever,  alcoholic  delirium,  cocaine 
intoxication  or  narcosis. 

Patients  suffering  from  deception  of  the  sense  of  taste  usually 
examine  their  food  most  carefully,  mixing  it,  tasting  a  bit  here 
and  there,  or  taking  some  of  it  in  the  mouth,  spitting  it  out 
again  and  refusing  to  eat  at  all.  Others  are  constantly  ex- 
pectorating, believing  their  saliva  to  be  poisoned  and  fearing 
to  swallow  it.  Patients  with  olfactory  hallucinations  sniff 
around,  hold  their  nostrils,  close  or  suddenly  open  the  window 
In  order  to  rid  themselves  of  the  hallucinated  vapor  or  odor. 

The  body  itself  of  some  insane  patients  emits  a  peculiar  odor 
by  which  these  persons  may  at  once  be  recognized.  Usually 
this  odor  disappears  with  a  return  of  health  and  therefore  seems 
to  be  connected  with  some  disorder  of  the  secretory  organs.  This 
would  accord  with  the  newer  investigations  regarding  the  duct- 
less glands  (thyroid,  ovaries,  epididymides,  etc.)  according  to 
which  these  organs  exert  an  important  bearing  upon  the  pro- 
duction and  development  of  certain  psychoses. 

Finally,  in  so  far  as  sense  deceptions  are  concerned,  I  would 
say  that  there  exists  no  special  objective  characteristic  by  means 
of  which  we  can  determine  whether  the  disorders  of  general 
body  sensation  of  which  certain  patients  complain  are  hallu- 
cinatory or  not.  In  many  instances,  special  consideration  should 
be  given  to  the  appearance  of  the  clothing  and  the  care  of  the 
bodies  of  insane  patients,  for  these  often  enable  us  to  arrive 
at  important  diagnostic  and  prognostic  conclusions. 

In  melancholiacs  and  often  also  in  paretics  neglect  of  the 
body  is  an  early  symptom  of  the  psychosis.    On  the  other  hand, 


116     THE  UNSOUND  MIND  AND  THE  LAW 

it  is  a  sign  of  incipient  improvement  when  patients  begin  again 
to  care  for  their  appearance  and  clothe  themselves  with  atten- 
tion. In  nearly  all  excited  patients,  the  clothing  is  disordered, 
while  in  dements  it  is  usually  soiled  and  dirty  as  a  result  of 
their  persistent  salivary  dribbling.  In  alcoholics  this  neglect  of 
person  and  clothing  may  be  used  as  a  direct  measure  for  the 
degree  of  deterioration.  We  need  not  despair  of  the  drinker 
who  clothes  himself  with  care.  Many  insane  persons  dress  and 
drape  themselves  in  a  most  remarkable  manner,  particularly 
when,  dominated  by  their  ideas  of  grandeur,  they  endeavor  to 
attract  attention.  In  this  event  we  find  women  dressing  their 
hair  in  the  most  extraordinary  fashion,  and  men  wearing  their 
beards  and  hair  in  astonishing  ways.  The  patient  suffering 
from  religious  paranoia  will  wear  his  hair  and  beard  very  long 
and  costume  himself  so  as  to  be  taken  for  an  apostle  or  a 
prophet.    In  many  insane  the  hair  grows  gray  prematurely. 

We  thus  see  that  we  must  distinguish  two  extremes  in  the 
outward  appearance  of  the  insane — upon  the  one  hand  we  have 
fantastic  adornment  and  upon  the  other  complete  neglect,  both 
expressing  the  alteration  of  personality  that  has  taken  place. 

In  many  insane  the  physiognomy  also  is  most  characteristic. 
Unfortunately,  however,  it  is  rarely  possible  to  obtain  a  photo- 
graph of  the  insane  that  will  actually  reproduce  this  charac- 
teristic expression.  Of  course  this  is  due  to  the  fact  that  the 
preparations  made  for  taking  the  picture  will  distract  the  pa- 
tient's attention  from  the  morbid  notions  that  are  present  and 
which  in  them  determine  the  characteristic  expression  that  we 
are  endeavoring  to  fixate. 

Dornblueth,  while  studying  the  old  paintings  in  European 
galleries,  found  many  in  which  the  artists  had  most  perfectly 
represented  the  physical  expression  of  the  most  varied  patho- 
logical emotional  states.  This  graphic  fixation  of  depression, 
exaltation,  fear  and  overbearance  was  possible  of  course  only 
because  the  patients  did  not  realize  they  were  being  observed. 

Not  infrequently  the  very  first  view  of  a  person,  his  appear- 
ance and  the  surroundings  which  he  has  made  for  himself,  will 
enable  us  to  recognize  that  he  is  insane.  In  most  instances, 
unfortunately,  the  physician  has  no  opportunity  of  studying  the 
patient's  comportment  unobserved.  When  he  visits  the  patient 
much  that  would  have  been  significant  has  been  put  in  order 


THE  EXAMINATION  OP  THE  INSANE     117 

by  the  relatives,  just  as  they  inadvertently  fail  to  disclose  or 
wilfully  distort  much  of  the  previous  history.  For  this  reason 
it  is  of  special  importance  at  the  very  first  interview,  and  before 
any  actual  physical  and  mental  examination  has  been  under- 
gone, to  pay  attention  to  any  external  evidences  that  might  give 
an  indication  of  the  existence  of  mental  disorder. 

Above  all  we  find  the  so-called  degenerative  signs  present 
in  many  insane.  At  any  rate  such  signs  are  more  often  present 
in  them  than  they  are  in  normally  constituted  individuals.  The 
skull  may  be  very  much  larger  or  smaller  than  the  average; 
such  abnormal  enlargement  may  be  due  to  hydrocephalus,  the 
vertex  then,  as  though  inflated,  overtopping  the  relatively  small 
face,  or  it  may  be  dependent  upon  rhachitis,  in  which  case  the 
forehead  appears  broad,  steep  and  advancing.  Withal,  notwith- 
standing the  large  circumference  of  the  skull,  the  brain  itself 
may  be  smaller  than  normal,  or  it  may  be  large  but  with  a 
poor  cortical  development,  as  is  the  case  in  idiocy.  On  the  other 
hand,  the  skull  may  be  very  small,  yet  mental  development  not 
be  noticeably  affected.  The  highest  degree  of  microcephaly,  in 
which  the  skull  appears  as  though  it  were  cut  off  above  and 
behind  the  ears  and  is  apparently  unable  to  contain  half  of  a 
normal  brain,  is  occasionally  found  in  feebleminded  persons 
with  a  fair  amount  of  intelligence.  Nevertheless,  these  devia- 
tions in  size,  as  well  as  asymmetry  of  the  skull,  inordinate  de- 
velopment of  the  upper  or  lower  jaw,  high  vaultedness  or  flat- 
ness of  the  palate,  cleft  palate  and  hare-lip,  marked  irregularity 
in  the  position,  or  non-development,  of  certain  teeth,  malforma- 
tion of  the  ear  lobes,  eoloboma  and  congenital  spots  of  pigment 
on  the  iris,  etc.,  are  all  signs  of  an  imperfect  physical  structure, 
which  often  has  its  prototype  in  a  definite  mental  constitution. 
The  prognathic  facial  formation,  characterized  by  protruding 
cheek  bones  and  jaws,  broad-rooted  nose  and  widely  separated 
eyes,  is  especially  significant  of  idiocy.  A  similar  significance 
must  be  attributed  to  certain  changes  of  the  rest  of  the  body, 
as  for  instance  goiter,  whose  influence  upon  psychic  functions 
has  been  more  clearly  recognized  during  the  last  few  years, 
rhachitis,  deformations  of  the  long  bones,  marked  deviation  in 
growth,  dwarfism,  acromegaly,  albinism,  malformations  of  the 
sexual  organs,  etc. 

As  I  have  explained  in  considering  the  causes  of  disease, 


118     THE  UNSOUND  MIND  AND  THE  LAW 

the  general  nutritional  state  bears  a  close  relationship  to  mental 
life.  Special  significance  attaches  to  all  states  of  bodily  weak- 
ness when  accompanied  by  nervous  disturbances,  with  anaesthesia 
or  hyperesthesia  of  special  tense,  or  with  neuralgias  and  vaso- 
motor disorders,  because  all  of  these  may  form  the  basis  for 
erroneous  notions  or  may  augment  until  they  themselves  repre- 
sent a  state  of  psychic  disease.  An  equally  instructive  point  is 
the  determination  of  the  body  weight,  which  decreases  regularly 
in  acute  forms  of  mental  disease  and  increases  when  recovery 
or  a  transition  into  dementia  sets  in.  During  the  excited  period 
of  a  manic  depressive  psychosis  the  body  weight  not  infre- 
quently increases,  while  in  acute  mania  a  loss  of  weight  is  reg- 
ularly observed.  In  the  chronic  psychoses  the  patient's  weight 
changes  as  it  does  in  health,  conformably  with  external  condi- 
tions; it  is  only  in  general  paresis  that  we  usually  note  a  pro- 
gressive increase  in  weight  which  later  gives  way  to  a  steady 
loss. 

In  various  mental  diseases  the  body  heat  often  deviates  from 
the  normal  without  any  external  or  accidental  influence  being 
present  to  account  for  the  change.  In  melancholia  the  tempera- 
ture usually  is  somewhat  reduced,  this  condition  being  often 
most  pronounced  in  the  evening,  although  any  intercurrent 
paroxysm  of  fear  may  be  the  cause  of  the  lowest  temperature 
of  the  day.  In  mania  the  body  heat  is  increased  by  about  a 
degree  Fahrenheit  during  the  excited  periods.  In  acute  con- 
fusional  insanity  the  evening  maximal  temperature  is  often 
absent,  but  marked  variations  are  evident  and  an  irregular  rise 
often  occurs  during  the  day  independent  of  any  emotion  or 
excitement.  The  temperature  in  hysterical  mental  states  is  sub- 
ject to  very  similar  variations.  In  stupor  it  is  usually  reduced, 
while  in  the  more  severe  cases  of  acute  confusional  insanity 
high  fever  occurs  during  the  delirium.  In  dementia  paralytica 
a  constant  slight  rise,  with  marked  exacerbations,  or,  on  the  other 
hand,  with  a  fall  of  even  as  much  as  10°  F.  after  a  paralytic 
attack,  is  not  unusual.  The  pulse  usually  is  normal  in  frequency 
but  in  states  of  stupor  is  often  retarded.  In  such  stuporous,  as 
well  as  in  depressive  states,  it  is  often  of  high  tension,  while  in 
the  terminal  state  of  dementia  paralytica  it  is  flaccid  and  di- 
crotic. During  an  attack  the  tension  is  somewhat  increased.  The 
Llood  pressure  is  not  increased  in  any  of  the  psychoses  except 


THE  EXAMINATION  OF  THE  INSANE      119 

in  those  associated  with  advanced  age.  The  increased  blood 
pressure  so  often  found  in  cases  of  the  latter  class  is  not  related 
to  the  psychosis  as  such  but  is  part  of  a  general  arteriosclerotic 
state  in  which  blood  pressure  is  often  high. 

Changes  in  the  quantity  and  consistency  of  the  urine  bear 
no  special  relationship  to  any  form  of  mental  disorder.  Albu- 
min, without  disease  of  the  kidneys,  may  be  found  in  the  urine 
after  epileptic  attacks,  in  delirium  tremens  and  in  paresis — in 
the  latter  particularly  after  the  paralytic  attacks.  Glycosuria 
occurs  no  more  frequently  in  the  insane  than  in  persons  who 
are  mentally  healthy. 

Menstruation  usually  ceases  during  attacks  of  acute  mental 
disease,  frequently  setting  in  again  when  improvement  takes 
place  and  often  doing  so  only  after  recovery  has  become  com- 
plete. In  chronic  and  incurable  cases  there  is  usually  no  men- 
strual disturbance. 

The  increase  of  salivary  secretion  that  occasionally  takes  place 
can  be  determined  only  with  difficulty,  because  the  salivary 
dribbling  often  noticed  in  stupor  and  demented  patients  is  sim- 
ply the  result  of  lack  of  attention  and  mechanical  control  and 
is  not  due  to  an  actual  increase  in  salivary  production. 

In  all  states  of  depression,  digestive  disorders  are  particularly 
frequent  and  these  in  turn  react  injuriously  upon  the  mental 
state. 

Sleep  is  usually  markedly  disordered  in  all  acute  psychoses. 
In  chronic  mental  disease  sleep  disorder  occurs  as  a  rule  only 
in  consequence  of  affects. 

In  some  cases  the  employment  of  the  otoscope  and  ophthal- 
moscope will  disclose  important  findings.  These  methods  of 
examination  will  of  course  not  enable  us  to  recognize  the  exist- 
ence of  a  psychosis,  but  they  are  of  diagnostic  value  in  deter- 
mining the  presence  of  some  disease  of  the  peripheral  sensory 
organs  which  might  be  the  cause  of  existing  sense  deceptions. 

Speech  and  handwriting,  entirely  aside  from  the  confusion 
of  their  contents,  may  give  many  valuable  indications  through 
their  form  and  structure.  The  excessively  rapid  speech  of  the 
maniac  accords  with  his  handwriting,  in  which,  on  account  of 
the  flight  of  ideas,  too  little  time  is  given  to  the  complete  for- 
mation of  single  words  or  no  attention  is  paid  to  punctuation. 
The  uncontrolled  motor  agitation  also  becomes  manifest  in  the 


120     THE  UNSOUND  MIND  AND  THE  LAW 

constant  underscoring  of  words,  bracketing  of  sentences,  and 
the  disfigurement  of  the  entire  page  with  ink  marks,  lines  and 
curves. 

On  account  of  his  mental  inhibition,  the  melancholiac  can 
neither  speak  nor  write  connectedly ;  at  most  he  can  utter  a  few 
hesitating  words  and  sentences,  and  he  is  able  to  write  still  less. 
All  other  forms  of  mental  disorder  are  also  characterized  by 
individual  modes  of  speech  and  handwriting,  concerning  which 
more  will  be  said  in  the  chapter  on  special  diagnosis. 

It  was  my  wish  at  the  present  moment  merely  to  indicate  that 
observation  of  the  patient  will  furnish  certain  valuable  diag- 
nostic objective  clues,  provided  of  course  that  these  objective 
changes  be  not  directly  related  to  purely  bodily  causes  or  that 
the  existing  psychosis  be  not  associated  with  some  infectious 
state  or  other  pathological  condition  in  consequence  of  which  a 
mixed  symptom  complex  is  produced. 

C.  Physical.  Examination 

The  physical  examination  should  consist  of  two  parts:  first, 
a  general  inspection  of  the  anatomic-physiologic  relations,  and 
second,  a  special  examination  of  the  nervous  system. 

1.   ANATOMIC-PHYSIOLOGIC  RELATIONS 

More  recently  there  has  been  a  leaning  of  psychiatry  toward 
the  special  characterization  of  the  psychically  abnormal  indi- 
vidual in  accordance  with  his  outward  conformation.  This — 
so  to  say — zoological  procedure  has  found  its  most  extreme  ex- 
ponent in  Lombroso  and  in  his  doctrine  of  the  congenital  crim- 
inal, who,  he  maintains,  represents  a  special  anthropological 
type  with  definite  physical  and  psychic  characteristics  of  de- 
generation. 

The  Lombroso  school  lays  greatest  stress  upon  a  recognition 
of  the  so-called  signs  of  degeneracy  which  are  interpreted  to 
be  manifestations  of  regression  to  an  earlier  developmental  stage 
(atavism)  and  which  occupy  but  a  subordinate  place  in  modern 
psychiatry.  This  doctrine  of  degenerative  stigmata  has  been 
elaborated  so  that  it  may  be  said  to  constitute  an  inane  pastime, 
a  mechanical  interpreting  of  signs;  hence  its  results  should  be 


THE  EXAMINATION  OF  THE  INSANE     121 

diagnostically  utilized  with  the  utmost  caution.  Nevertheless, 
psychiatry  cannot  renounce  any  source  of  information.  The 
entire  individual  must  always  be  considered  and  an  endeavor 
should  be  made  to  discover  all  those  relations  that  undoubtedly 
exist  between  the  psychic  manifestations  of  life  and  the  bodily 
processes  but  which  our  present  means  of  investigation  have  not 
yet  been  able  to  disclose.  We  still  have  no  scientific  explanation 
for  these  relations,  and  therefore  must  be  satisfied  with  a  precise 
description  of  certain  anatomic-physiologic  conditions  which  ex- 
perience has  taught  us  to  look  upon  as  indications  or  accom- 
paniments of  mental  disorder. 

Of  these,  perhaps,  the  form  of  the  skull  should  first  be  con- 
sidered as  likely  to  furnish  us  with  some  information — yet  all 
deductions  from  such  a  study  should  be  carefully  controlled, 
lest  they  lead  to  fantastic  exaggerations  similar  to  those  that 
have  formed  the  basis  of  Gall's  "Phrenology."  Up  to  the 
present  it  has  not  been  demonstrated,  except  in  very  few  preg- 
nant instances,  that  any  direct  relationship  exists  between  the 
psychoses  and  skull  formation.  Nevertheless  it  is  necessary  that 
the  skull  be  carefully  examined  in  all  instances.  This  may  be 
done  by  three  simple  methods — inspection,  palpation,  and  men- 
suration. 

By  means  of  inspection  we  can  determine  whether  there  exists 
any  asymmetry  in  the  conformation  of  the  skull.  Often  it  is 
most  easy  to  recognize  such  asymmetry  when  the  skull  is  viewed 
from  above.  Slight  asymmetries  in  the  conformation  of  the 
skull  and  its  component  parts,  such  as  a  marked  prominence 
of  one  frontal  region,  are  very  frequent  and  occur  so  often  in 
normal  individuals  that  they  are  of  no  diagnostic  significance. 
More  pronounced  asymmetries  are  encountered  in  many  psy- 
choses, especially  in  idiocy  and  epilepsy.  Palpation  of  the  skull 
will  give  us  information  regarding  the  location  of  the  sutures 
and  possibly  an  indication  as  to  the  relative  size  of  the  indi- 
vidual lobes  of  the  brain.  Ossification  of  the  sutures  may  easily 
be  determined  and  after  one  has  had  some  practise  in  palpating 
the  skull  the  normal  sutures  can  be  recognized  without  difficulty. 
In  all  cases  in  which  such  examination  of  the  skull  seems  to 
be  important,  the  scalp  should  be  shaved  and  the  sagittal,  lamb- 
doidal  and  coronal  sutures  marked  upon  it  by  means  of  an  ani- 
line pencil.    Measurement  of  the  skull  is  carried  out  partly  with 


122     THE  UNSOUND  MIND  AND  THE  LAW 

a  tape  measure,  partly  with,  calipers.  Normally  the  largest 
horizontal  circumference  taken  at  a  level  of  the  glabella  and 
external  occipital  protuberance  is  forty-eight  to  fifty-six  centi- 
meters; the  longitudinal  diameter,  between  the  glabella  and 
occipital  protuberance,  sixteen  to  eighteen  centimeters ;  the  larg- 
est transverse  diameter  between  the  two  most  distant  lateral 
points  of  the  skull,  fourteen  to  fifteen  centimeters.  A  determina- 
tion of  the  proportions  of  the  skull,  the  so-called  cephalic  index, 
may  be  of  some  value.  This  is  the  ratio  of  maximum  length 
to  maximum  width.  Skulls  with  an  index  of  seventy-five  or 
less,  that  is,  when  the  width  is  three-quarters  or  less  of  the 
length,  are  considered  dolicocephalic  or  long  skulls.  Those  of 
an  index  of  eighty  or  over  are  brachycephalic  or  broad  skulls. 
Intermediate  indices,  between  seventy-five  and  eighty,  are  con- 
sidered mesocephalic.  Malformations  of  the  skull  are  most  fre- 
quently encountered  in  idiocy  and  epilepsy.  In  hydrocephalus 
the  horizontal  circumference  may  be  sixty  centimeters  and  more 
and  the  transverse  diameter  seventeen  centimeters  and  over, 
while  in  microcephalus  the  horizontal  circumference  may  not 
reach  forty  centimeters  and  the  transverse  diameter  not  twelve 
centimeters. 

It  would  seem  that  the  anthropometrical  skull  measurements 
have  thus  far  not  furnished  results  available  for  psychiatric 
diagnosis  that  are  commensurate  with  the  time  and  care  they 
require.  For  all  practical  purposes  the  facts  we  have  given 
will  suffice.  The  examination  of  the  skull  may  be  followed  by 
an  examination  of  the  rest  of  the  head.  Among  the  so-called 
degenerative  signs  that  may  be  found  during  such  examination 
are  marked  prominence  of  the  jaws  (prognathism),  asymmetries, 
high  vaultedness  of  the  hard  palate,  inequality  of  the  two  halves 
of  the  face,  hare-lip  and  cleft  palate. 

The  hair  of  the  head  of  insane  patients  often  becomes  pre- 
maturely gray  or  loses  its  luster  and  becomes  fragile.  Other 
anomalies  in  the  growth  of  the  hair  have  also  been  described 
as  degenerative  signs,  but  these  in  our  opinion  are  of  no  prac- 
tical value.  The  growth  of  the  hair  upon  the  rest  of  the  body 
often  shows  various  noticeable  abnormalities.  The  anomalies 
of  the  teeth  regarded  as  signs  of  degeneracy  are  irregularity 
of  position  and  abnormality  in  size.  The  formation  known  as 
Hutchinson's  teeth  is  most  often  encountered  in  hereditary  lues. 


THE  EXAMINATION  OF  THE  INSANE     123 

During*  an  attack  of  convulsions  epileptics  sometimes  break  single 
teeth;  the  finding  of  tooth  fragments  therefore  may  lead  one 
to  suspect  the  existence  of  epilepsy,  but  in  itself  this  by  no 
means  warrants  the  conclusion  that  epilepsy  is  actually  present. 
In  this  connection  it  may  be  well  to  reiterate  that  the  presence 
of  any  of  the  so-called  degenerative  signs,  taken  alone,  is  never 
sufficient  reason  for  concluding  that  a  psychosis  exists.  Such 
signs  merit  consideration  only  when  they  are  associated  with 
other  psychopathic  symptoms. 

Certain  observers  base  their  psychiatric  deductions  in  part 
upon  the  conformation  of  the  external  ear;  and  quite  a  series 
of  abnormal  or  anomalous  ear  formations  have  been  classed 
among  the  degenerative  signs.  For  instance,  importance  has 
been  attached  to  asymmetry  as  to  seat  and  size,  unusual  promi- 
nence of  the  entire  auricle,  a  more  or  less  prominent  helix  with 
or  without  a  tubercle  upon  its  border  (the  Darwinian  ear),  a 
preeminence  of  the  anthelix  (the  Wildermuthian  ear),  an  absent 
helix  (Morelian  ear),  an  absent  anthelix,  an  attachment  between 
anthelix  and  helix,  accessory  anthelices,  coloboma  lobuli,  etc. 
As  a  matter  of  curiosity,  let  it  be  mentioned  that  some  of  the 
older  psychiatrists  looked  upon  softness  of  the  ear  as  an  un- 
favorable sign.  As  a  matter  of  fact  the  chronic  insane  do  often 
have  very  soft  but  otherwise  well-formed  ears,  which  may  be 
folded  together  like  thin  cloth. 

Among  the  degenerative  signs  found  in  the  visual  organ,  the 
following  have  been  enumerated :  an  abnormal  entrance  of  the 
central  retinal  artery,  albinism,  coloboma  of  the  iris  and  irreg- 
ular pigmentation  of  the  choroid. 

Habitual  luxation  of  the  extremities,  Polydactyly,  web  fingers, 
nsevi,  exaggerated  growth  of  hair  upon  the  body  and  closely 
approximated  eyebrows,  are  all  said  to  be  degenerative  signs. 
A  somewhat  greater  significance  should  be  attached  to  congenital 
deafness  and  blindness,  as  well  as  to  anomalies  of  the  sexual 
organs  and  to  their  dependent  sexual  differentiations.  Such 
anomalies  are  not  infrequently  encountered  in  insane  persons 
and  in  general  probably  do  indicate  a  marked  degeneracy.  They 
are:  a  feminine  build  of  the  body  in  man  (broad  pelvis,  female 
breasts)  and  a  male  habitus  in  women  (developmental  faults 
in  the  pelvis  and  thorax,  beardedness,  deepness  of  voice),  con- 
genital sterility,  hermaphroditism,   epispadia  and  hypospadia, 


124     THE  UNSOUND  MIND  AND  THE  LAW 

eryptorchism,  uterus  bicornis,  atresias.  It  appears  to  be  certain 
that  women  of  markedly  inherited  psychopathic  taint  not  infre- 
quently show  developmental  disorders  as  a  result  of  which  their 
capacity  for  child  bearing,  or  for  nursing  children  when  they 
do  bear  them,  is  restricted,  and  the  maintenance  of  the  race  thus 
endangered. 

No  matter  in  what  form  these  signs  of  degeneracy  may  mani- 
fest themselves,  it  is  as  yet  impossible  to  explain  the  causal 
relationship  that  exists  between  degenerative  signs  and  psychic 
disorder,  or  to  trace  the  relationship  between  certain  bodily 
characteristics  and  certain  mental  diseases.  Hence  these  signs 
of  degeneracy  do  not  possess  any  great  diagnostic  significance, 
notwithstanding  that  frequently  individuals  who  bear  many 
such  signs  must  be  looked  upon  as  degenerates  or  as  particularly 
predisposed  to  the  development  of  psychoses.  What  is  much 
more  easily  understood  is  the  tendency  of  the  blind  or  deaf  to 
develop  mentally  in  an  abnormal  way,  for  the  absence  of  im- 
portant sense  perceptions  must  necessarily  inhibit  the  intel- 
lectual growth.  How  we  are  to  understand  the  connection  or 
the  reciprocal  relationship  that  is  supposed  to  exist  between  in- 
dividual physical  and  mental  signs  of  degeneracy  can  at  most 
be  a  question  of  surmise.  It  would  be  absurd  to  maintain  that 
prognathism  is  the  cause  of  a  psychic  defect  or  on  the  other 
hand  that  the  psychic  defect  is  the  cause  of  the  prognathism. 

Probably  the  same  cause  that  has  brought  about  the  prog- 
nathism has  also  been  active  in  the  production  of  the  psychic 
defect.  Other  manifestations  are  probably  to  be  explained  in  a 
similar  way.  Together  with  the  physical  signs  there  may  also 
be  present  certain  psychic  signs  of  degeneracy,  the  latter  term 
being  employed  to  cover  all  those  psychopathological  traits 
through  which  the  psychic  equilibrium  of  the  entire  personality 
is  disturbed  and,  frequently  enough,  the  social  existence  of  the 
individual  endangered.  In  the  class  of  desequilibres  who  show 
such  psychic  defects  belongs  a  large  number  of  very  talented 
persons.  The  disharmony  of  psychic  functions  in  these  people 
is  caused  by  a  strong  predominance  of  certain  traits  associated 
with  a  dwarfing  of  certain  others.  Marked  intellectuality  ac- 
companied by  feeble  will  power,  an  abnormally  vivid  imagina- 
tion accompanied  by  a  lack  of  judgment,  preeminent  animal 
instincts  associated  with  a  lack  of  ethical  qualities,  constitute 


THE  EXAMINATION  OF  THE  INSANE     125 

the  most  frequent  examples  encountered  in  this  group.  Many- 
sexual  perverts,  many  pathological  swindlers,  confidence  men 
and  other  criminals,  as  well  as  many  talented  persons  of  the 
underworld,  are  found  among  these  desequilibres. 

Almost  all  of  them  show  a  marked  intolerance  to  alcohol, 
and  hence  this,  too,  may  be  looked  upon  as  a  sign  of  degenera- 
tion, assuming  of  course  that  it  is  associated  with  other  patho- 
logical characteristics. 

After  the  presence  of  signs  of  degeneracy  has  been  determined, 
an  examination  of  the  internal  organs  of  the  body  should  follow. 
Special  attention  should  be  given  to  the  lungs,  inasmuch  as 
tuberculosis  is  very  frequently  found  associated  with  psychoses 
of  various  kinds.  Katatonics  with  persistent  general  muscular 
spasm,  melancholiacs  and  stuporous  patients,  are  most  prone  to 
this  complication  in  consequence  of  their  superficial  breathing. 

Salivary  secretion  is  often  increased,  especially  in  dementia 
praecox  and  other  katatonic  states.  Demented  and  stuporous 
patients  permit  the  saliva  to  dribble  from  their  mouths.  Para- 
noiacs  will  infrequently  be  found  expectorating  everywhere  in 
the  endeavor  to  throw  off  poison  which  they  believe  has  been 
introduced  into  their  bodies.  The  secretion  of  tears,  strange  to 
say,  is  usually  decidedly  diminished  or  entirely  arrested  in  true 
melancholia.  Many  melancholiacs  complain  that  the  solace  ob- 
tained by  shedding  tears  is  denied  them.  This  circumstance  may 
be  of  diagnostic  value  when  the  depressed  states  in  paresis  or 
hysteria  are  to  be  differentiated  from  true  melancholia,  for  in 
them  the  flow  of  tears  is  often  very  profuse. 

In  all  states  of  depression  digestive  disturbances,  more  par- 
ticularly intestinal  inertia,  are  often  present.  Disturbance  of 
micturition  is  encountered  in  the  most  varied  forms  of  mental 
disorder;  enuresis  nocturna  in  epilepsy;  paralysis  of  the  blad- 
der in  paresis,  retention  of  urine  in  hysteria  and  epilepsy. 
Careful  attention  should  be  given  by  the  examiner  to  the  cir- 
culatory organs.  Arteriosclerosis,  calcification  of  the  coronary 
arteries  and  angina  pectoris  are  encountered  not  only  in  paretics 
and  senile  patients  but  also  in  youthful  individuals.  It  is  clear 
that  the  disorders  of  brain  nutrition  caused  by  arterio- 
sclerosis must  be  of  great  significance  for  the  diagnosis  of  mental 
disease.  For  a  long  time  marked  stress  was  laid  upon  the  im- 
portance of  examination  of  the  blood.     It  now  becomes  more 


126     THE  UNSOUND  MIND  AND  THE  LAW 

and  more  clear,  however,  that  qualitative  and  quantitative  blood 
changes  are  not  sufficiently  characteristic  to  be  of  assured  value 
in  diagnosis  and  differential  diagnosis.  There  exists  no  anosmia, 
plethora,  leucocytosis,  polycythemia,  poikilocytosis,  etc.,  that  may 
be  considered  a  specific  criterion  of  any  definite  psychosis.  Prob- 
ably with  an  improvement  in  our  microscopical  technique  or 
with  a  discovery  of  still  other  chemical  reactions  this  statement 
may  require  modification,  but  as  yet  no  psychiatric  diagnosis 
can  be  made  from  the  blood  findings  alone.  On  the  other  hand, 
the  Wassermann  reaction  is  truly  valuable,  for  by  this  means  we 
are  able  to  recognize  with  certainty  the  presence  of  syphilis. 

The  investigations  of  "Wassermann  and  others  have  lent  such 
great  significance  to  the  examination  of  the  blood  that  no 
psychiatric  diagnosis  can  be  considered  valid  unless  this  reaction 
test  is  made.  Wheresoever  the  reaction,  the  nature  of  which 
need  not  be  described  here,  is  positive  the  patient  may  be  assumed 
to  be  syphilitic.  The  cerebrospinal  fluid,  obtained  by  means 
of  lumbar  puncture,  should  in  all  doubtful  cases  be  subjected 
to  the  same  test,  for  not  infrequently  the  blood  may  give  a 
negative  reaction  to  the  Wassermann  test,  while  the  spinal  fluid 
gives  a  positive  one.  The  spinal  fluid  should  also  be  examined 
in  regard  to  its  cell  and  globulin  contents.  It  has  been  shown 
that  in  certain  organic  diseases  of  the  nervous  system  the  cel- 
lular elements  of  the  cerebrospinal  fluid  are  materially  increased 
(lymphocytosis)  and  that  in  these  same  diseases  an  opalescence 
or  even  a  pronounced  turbidity  will  be  produced  by  mixing  a 
cold  saturated  neutral  solution  of  sulfate  of  ammonium  with 
equal  parts  of  spinal  fluid  (globulin  reaction). 

The  Abderhalden  sero-diagnosis  is  a  method  of  blood  exami- 
nation which,  as  yet,  cannot  be  said  to  have  fulfilled  expecta- 
tions. The  most  we  can  say  of  it  is  that  the  "defensive  fer- 
ments" have  given  satisfactory  information  in  testing  the  or- 
ganic functions  in  a  series  of  cases.  Very  recently  the  defensive 
ferments,  or  rather  the  reactions  that  indicate  their  presence 
in  the  blood,  have  played  an  important  role  in  the  recognition 
of  disorders  of  internal  secretion.  We  know  that  dysfunction 
of  the  thyroid  gland  and  other  ductless  glands  (hypophysis, 
parovaria,  etc.)  may  give  rise  to  psychic  disturbances.  The 
eminent  significance  of  the  defensive  ferments  for  psychiatric 
diagnosis,  therefore,  lies  in  the  possibility  of  being  able  by  their 


THE  EXAMINATION  OF  THE  INSANE     127 

aid  to  recognize  disturbances  of  internal  secretion,  at  a  time 
when  clinical  symptoms  are  as  yet  but  slightly  marked.  Never- 
theless we  should  not  forget  that  a  final  judgment  regarding 
the  value  of  Abderhalden 's  sero-diagnosis  in  psychiatry  and 
the  rest  of  medicine  is  not  yet  possible. 

No  physical  examination  would  be  complete  without  an  inves- 
tigation of  the  state  of  sexual  excitability.  This  will  be  found 
increased  in  mania  and  in  the  commencement  of  paresis  and  not 
infrequently  also  in  the  early  stages  of  senile  dementia.  On 
the  other  hand,  sexual  excitability  is  markedly  diminished  in  all 
states  of  depression  and  in  the  later  stages  of  all  dementias. 
It  is  entirely  lost  in  the  last  stages  of  alcoholism,  morphinism 
and  paresis. 

In  female  patients  inquiries  regarding  the  menstruation  should 
not  be  neglected.  The  menstrual  period  frequently  acts  upon 
the  patient  as  a  disturbing  factor.  Not  infrequently  the  men- 
struation disappears  during  a  psychosis,  only  to  reappear  when 
health  has  been  restored.  In  alcoholics  and  morphinists  the 
menses  often  cease.  Sometimes  the  onset  of  psychic  disorders  of 
a  borderline  type  may  be  directly  related  to  a  cessation  of 
ovarial  function.  This  applies  to  the  disorders  of  climacterium 
and  to  those  states  of  excitement  that  follow  operative  removal 
of  the  ovaries. 

The  body  weight  must  always  be  carefully  controlled.  This, 
however,  is  more  of  prognostic  than  diagnostic  value.  In  general 
the  body  weight  declines  in  all  acute  psychoses  and  returns  to 
normal  with  the  beginning  of  a  return  to  health.  Not  infre- 
quently the  bodily  condition  begins  to  improve  and  the  weight 
starts  increasing  before  any  amelioration  in  the  mental  state 
can  be  noticed.  When  the  body  weight  steadily  increases  with- 
out being  accompanied  by  any  improvement  in  the  mental  state, 
the  prospects  for  recovery  become  less  favorable.  Depressive 
patients  who  accumulate  fat,  in  fact  all  insane  patients  who 
gain  weight  rapidly  under  normal  dietetic  conditions,  should 
arouse  suspicion  of  a  beginning  dementia.  Another  common 
sign  of  dementia,  particularly  in  youthful  individuals,  is  the 
voracity  that  may  be  the  cause  of  the  adiposity.  In  some  cases 
of  paresis  and  melancholia  the  body  weight  decreases  enor- 
mously, even  when,  on  account  of  the  refusal  to  take  food,  the 
nourishment  of  the  patient  is  effected  by  means  of  a  stomach 


128     THE  UNSOUND  MIND  AND  THE  LAW 

tube  and  when  organic  changes  of  the  digestive  tract  cannot 
be  found. 

Finally  we  proceed  to  an  examination  of  the  pulse,  temperature 
and  urine.  In  stuporous  states  the  pulse  is  often  retarded  to 
fifty  or  less  per  minute;  in  excited  states  it  is  accelerated.  A 
contraction  of  the  radial  arteries  is  found  in  states  of  stupor 
and  melancholia. 

During  the  convulsive  attacks  of  paretics  and  epileptics  the 
temperature  is  often  increased.  "When  a  reduction  of  tempera- 
ture below  90  degrees  F.  occurs  in  paresis,  as  it  not  infrequently 
does,  it  is  indicative  of  a  beginning  moribund  state. 

The  urine  is  often  markedly  diminished  in  depressive  and 
stuporous  states  and  frequently  increased  in  paresis.  Albumin 
is  found  in  the  urine  of  alcoholics  and  paretics,  and  in  that 
of  epileptics  after  a  series  of  attacks;  sugar  is  found  in  the 
urine  of  paretics,  acetone  bodies  in  that  of  patients  whose  nutri- 
tion has  been  markedly  reduced  as  a  result  of  their  refusal  to 
take  food  and  also  in  paretics  with  digestive  disturbances.  Often 
in  the  latter  indican  will  also  be  found  in  the  urine. 

2.   THE  NERVOUS   SYSTEM 

After  we  have  determined  the  presence  or  absence  of  ana- 
tomic-physiologic deviations  and  of  those  physical  and  psychic 
traits  that  modern  teachings  look  upon  as  signs  of  degeneration, 
and  after  the  general  physical  examination  has  been  completed, 
we  should  next  enter  upon  the  special  examination  of  the  nervous 
system.  This  is  of  the  utmost  importance — especially  for  the 
diagnosis  of  dementia  paralytica.  Attention  should  first  be  given 
to  the  pupils.  Pupilary  difference  is  often  found  in  paresis,  but 
often  also  in  psychoses  of  other  nature  and  even  in  normal  per- 
sons. Considered  by  itself,  such  inequality  has  but  limited  diag- 
nostic value.  Sluggishness  of  the  pupilary  reaction  is  character- 
istic of  alcoholism  and  paresis;  contracted  pupils  speak  for  mor- 
phinism and  tabo-paresis ;  dilated  pupils  for  epilepsy,  paresis  and 
coeainism ;  reflex  pupilary  rigidity  is  indicative  of  alcoholic  in- 
toxication, senile  dementia  and  dementia  paralytica,  and  loss 
of  convergence  reaction  of  paresis.  The  presence  of  pupilary 
rigidity  in  a  middle-aged  person  with  mental  disorder  should 
always  arouse  the  suspicion  of  paresis. 


THE  EXAMINATION  OF  THE  INSANE     129 

Weakness  or  paralysis  of  the  ocular  muscles  (ptosis,  strabis- 
mus, etc.)  is  encountered  in  brain  syphilis,  paresis  and  the 
alcoholic  psychoses,  nystagmus  in  paresis  and  other  organic 
diseases  of  the  brain.  Contraction  of  the  visual  field,  clonic 
spasm  of  the  lids  (blepharospasm)  and  rolling  of  the  eyeballs 
are  indicative  of  hysteria. 

The  disorders  of  facial  innervation  that  are  important  for 
psychiatric  diagnosis  are  as  follows: 

Asymmetry  of  the  two  sides  of  the  face — this,  when  not  con- 
genital, often  constitutes  a  disorder  of  innervation  that  is  symp- 
tomatic of  paresis. 

Associated  movements — a  frequent  symptom  in  paresis;  in 
talking,  opening  the  mouth,  protruding  the  tongue,  a  large  part 
of  the  facial  territory  or  the  entire  facial  territory  often  becomes 
energized  at  the  same  time,  so  that  an  actual  undulation  of  the 
facial  muscles  sets  in.  Similar  associated  movements  are  met 
with  in  stutterers  and  idiots. 

Tremor  of  the  lips  in  alcoholics  and  paretics. 

Unequal  innervation  of  the  two  halves  of  the  soft  palate  in 
paresis. 

The  disturbances  of  hypoglossal  innervation  encountered  are 
tremor  and  ataxia  of  the  tongue  in  alcoholics  and  paretics; 
fibrillary  twitchings  in  paretics;  lateral  deviation  in  paretics 
and  apoplectics.  An  examination  of  speech  should  be  made, 
preferably  immediately  following  the  examination  of  the  tongue. 
This  will  be  found  particularly  valuable  in  the  diagnosis  of 
paresis.  In  the  beginning  of  this  disease  speech  is  often  merely 
hesitating,  retarded  and  peculiarly  tremulous.  Errors  of  speech 
are  infrequent  at  first,  but  can  often  be  elicited  even  at  this 
stage  by  asking  the  patient  to  repeat  certain  difficult  words. 
Soon  the  hesitating  speech  becomes  transformed  into  a  stutter- 
ing one ;  word  stumbling  sets  in  or  certain  syllables  are  entirely 
omitted.  At  the  same  time  the  voice  often  becomes  raucous  and 
monotonous,  and  in  some  patients  hoarse  or  nasal.  Ultimately 
speech  becomes  entirely  unintelligible  (ataxic  aphasia).  Some- 
times a  patient  under  examination  does  not  talk  at  all  and  every 
question  remains  unanswered.  This  symptom,  mutism,  is  of 
great  diagnostic  significance.  Complete  aphasia  may  be  the 
result  of  destruction  of  the  speech  center,  and  may  have  de- 
veloped gradually  from  the  earliest  degree  of  paretic  speech 


130     THE  UNSOUND  MIND  AND  THE  LAW 

disorder  or  may  have  come  on  suddenly.  Moreover,  complete 
aphasia  may  be  produced  by  apoplexy  or  may  be  the  result  of  a 
general  atrophy  that  has  involved  the  brain  cortex  without  nec- 
essarily implicating  the  speech  center.  Mutism  as  a  result  of 
an  apoplectic  attack  is  of  no  psychiatric  interest;  when  it 
occurs  in  consequence  of  cortical  atrophy,  it  is  indicative  of 
senile  dementia,  and  when  it  results  from  a  gradual  destruction 
of  the  frontal  brain  cortex,  it  is  characteristic  of  paresis. 
Mutism,  however,  it  not  always  indicative  of  an  organic  paral- 
ysis of  the  vocal  organs;  sometimes  the  paralysis  is  essentially 
functional  (hysterical)  in  nature  or  else  the  patient,  while  per- 
fectly able  to  use  his  vocal  organs,  does  not  do  so  because  he 
is  under  the  spell  of  delusions  which  forbid  him  to  speak.  It 
is  this  that  most  often  explains  the  mutism  of  patients  who 
are  in  a  state  of  stupor. 

Finally,  mutism  may  be  due  to  dementia.  Whereas,  in  the 
instances  previously  enumerated,  the  patient  undoubtedly  under- 
stands the  questions  put  to  him,  the  demented  person  is  mute 
because  he  is  entirely  unable  to  comprehend  the  sense  of  the 
questions  asked  and  has  no  ideational  store  upon  which  he  can 
draw.  Idiots  and  cretins  of  a  lower  grade  never  learn  to  speak 
because  they  have  no  ideas  which  they  might  express  in  words. 
In  other  instances,  where  there  is  a  question  not  of  congenital 
but  of  acquired  dementia,  the  loss  of  articulate  speech  consti- 
tutes part  of  the  increasing  dementia.  Errors  of  differential 
diagnosis  regarding  the  cause  of  total  aphasia  can  hardly  occur, 
for  if  the  patient  is  asked  to  give  the  reply  in  writing  he  will 
at  once  show  whether  he  has  understood  the  question  or  not. 
An  attempt  to  induce  a  mute  patient  to  write  should  always 
be  made,  as  many  important  disclosures  may  be  obtained  by  this 
means;  just  as  in  health,  many  of  the  patient's  characteristic 
traits  will  be  divulged  in  the  handwriting.  Particularly  can 
the  degree  of  a  person's  education  often  be  recognized  through 
a  glance  at  his  chirographic  productions  by  the  experienced 
observer.  For  the  psychiatrist,  however,  it  is  more  a  question 
of  a  study  and  analysis  of  the  form  and  contents  of  the  pa- 
tient 's  written  productions  than  of  the  handwriting  itself.  This 
examination  is  of  significance  not  only  for  the  psychiatric  diag- 
nosis of  the  individual  case  but,  in  certain  forensic  connections, 
it  may  also  constitute  the  sole  means  for  casting  light  upon  legal 


THE  EXAMINATION  OF  THE  INSANE     131 

questions.  "Where  this  contingent  arises  it  will  be  necessary  to 
obtain  writings  of  the  patient  executed  at  a  time  when  there 
was  no  question  of  the  existence  of  mental  disease,  and  to  com- 
pare them  with  the  later  ones.  Great  importance  has  always 
been  attached  to  the  examination  of  the  handwriting  in  paresis. 
Not  infrequently  an  alteration  of  the  handwriting,  especially 
in  the  case  of  well  educated  persons,  is  the  most  noticeable 
symptom  in  the  beginning  of  paresis.  The  diminished  efficiency 
of  the  nervous  system  demonstrates  itself  in  the  handwriting 
precisely  as  it  does  in  the  speech  utterances  and  in  other  dis- 
turbances of  function.  Early  in  the  course  of  paresis  the  hand- 
writing is  often  merely  disfigured  on  account  of  the  more  or 
less  marked  tremor  that  exists  The  formation  of  the  individual 
letters  shows  this  tremor  very  well.  Even  at  a  very  early  stage 
of  the  disease  the  handwriting  often  becomes  markedly  altered 
in  consequence  of  the  ataxia  of  the  hand  or  fingers  that  associates 
itself  with  the  irregular  muscular  tremor.  The  writing  becomes 
disorderly,  irregularly  undulating,  with  uncertainties  in  the  up 
and  down  strokes.  This  ataxic  writing  constitutes  a  transition 
to  the  paretic  handwriting,  in  which  the  existing  psychic  defect 
manifests  itself  in  a  more  or  less  drastic  manner.  The  patient 
omits  single  letters,  syllables,  or  even  entire  words,  makes  mis- 
takes in  spelling  and  errors  in  grammar  which  he  formerly 
would  never  have  made,  repeats  words  and  sentences,  makes 
frequent  corrections  and  erasures,  blots  and  defaces  the  page  so 
that  often  a  glimpse  of  the  writing  is  enough  to  establish  the 
diagnosis.  In  fact,  a  long  standing  symptom  complex  indicative 
of  paresis  should  become  questionable  if  it  fails  to  include  any 
disturbance  of  the  handwriting,  even  though  the  contents  of 
the  written  production  may  reveal  the  existence  of  delusions. 
Tremorous  writing  is  found  also  in  other  psychoses.  As  a  point 
of  differential  diagnosis  it  should  be  noted  that  tremorous  writ- 
ing without  ataxia,  in  fairly  distinct  wavy  lines  of  equal  size, 
is  characteristic  of  senile  dementia,  while  tremorous  writing  in 
fine  fairly  regular  undulating  lines  is  significant  of  alcoholic 
delirium.  The  writing  of  epileptics  who  have  tremor  is  also 
tremulous,  of  course,  but  the  undulations  are  more  irregular  and 
are  sometimes  interspersed  with  ataxic  excursions. 

Other  forms  of  psychic  disorder  are  characterized  less  by  the 
form  of  the  handwriting  than  by  the  contents  of  the  written 


132     THE  UNSOUND  MIND  AND  THE  LAW 

composition.  Thus  the  writings  of  juvenile  dements  are  found 
replete  with  senseless  phrases.  Those  of  paranoiacs  disclose  the 
delusions  that  they  otherwise  carefully  conceal.  In  those  of  the 
maniac  we  find  plainly  revealed  evidences  of  accelerated  flow  of 
ideas,  in  those  of  the  melancholiac  evidences  of  inhibited  flow 
of  ideas.  The  test  of  speech  and  handwriting,  however,  does 
not  complete  the  examination  of  the  nervous  system. 

Ophthalmoscopic  examination,  by  the  disclosure  of  choked 
disc,  will  often  show  the  presence  of  cerebral  neoplasm,  or  by 
the  demonstration  of  an  optic  atrophy  will  call  attention  to  an 
existing  tabes.  Certain  paralyses  may  be  recognized  as  hysteri- 
cal by  the  disorders  of  sensation  and  other  characteristic  symp- 
toms that  accompany  them.  Such  paralyses  will  disappear  when 
the  morbid  ideas  which  caused  the  disorder  of  function  have 
been  dispersed  by  suggestion  or  by  other  means.  The  organic 
paralysis  present  in  certain  psychoses  may  be  of  central  or 
peripheral  origin,  and  light  will  be  cast  upon  this  question  by 
an  examination  of  the  reflexes.  The  superficial  and  deep  reflexes 
should  of  course  be  examined  carefully  in  every  instance.  They 
will  often  be  found  increased  in  the  early  stages  of  paresis,  while 
in  the  late  stages  of  this  disease,  as  well  as  in  alcoholic  neuritis, 
they  are  often  absent.  Sensory  disturbances  are  encountered  as 
hypersesthesias  in  early  paresis,  as  hemianesthesia  in  hysteria, 
as  lancinating  pains  in  tabo-paresis,  as  headaches  and  migraine 
in  paresis  and  in  epilepsy,  etc.  All  these  points  will  receive 
more  specific  attention  in  the  following  chapters. 

D.  Testing  the  Mental  Behavior 

Thus  far  the  examination,  in  the  main,  has  been  confined  to 
an  external  observation  of  the  passive  patient.  From  such  ob- 
servation the  physician  has  obtained  a  general  impression  in 
regard  to  any  material  difference  that  may  exist  in  the  patient's 
appearance  and  comportment  from  that  existing  in  other  persons 
of  the  same  age,  sex,  and  position  in  life.  In  order,  however, 
that  he  may  gain  an  insight  into  the  psychic  and  physical  func- 
tional efficiency  of  the  patient,  a  further  examination,  one  that 
requires  the  patient's  cooperation,  is  necessary.  As  I  have 
already  stated,  special  consideration  will  determine  whether  in 
an  individual  case  the  mental  capacity  should  be  tested  first  and 


THE  EXAMINATION  OF  THE  INSANE     133 

the  condition  of  the  physical  organs,  the  reflexes,  etc.,  be  studied 
later,  or  whether  this  mode  of  procedure  should  be  reversed. 
Under  all  circumstances  the  physician  must  start  from  the  prem- 
ise that  no  immutable  standard  of  health  and  disease  exists,  and 
hence  the  result  of  any  investigation  can  be  of  value  only  in  so 
far  as  it  discloses  to  what  extent  the  efficiency  of  the  individual 
under  examination  remains  behind  that  of  the  other  individuals 
living  under  similar  condition  and  behind  his  own  former  capa- 
bilities. 

The  first  thing  to  be  tested  is  the  patient's  orientation  in 
regard  to  his  own  person,  in  regard  to  time,  space  and  sur- 
roundings. He  should  be  questioned  as  to  his  name,  age,  place 
of  birth,  parents,  brothers  and  sisters,  as  to  his  family  condi- 
tions and  occupation,  in  regard  to  the  present  day  of  the  week, 
the  month  and  the  year,  the  season  of  the  year,  and  his  present 
place  of  residence  or  sojourn.  Partial  or  complete  disorienta- 
tion is  a  symptom  of  the  greatest  diagnostic  significance;  con- 
sequently, in  every  case  of  mental  disease,  we  should  endeavor 
to  determine  precisely  whether  any  deficiency  in  the  power  of 
orientation  exists,  to  what  degree  disorientation  may  have  ad- 
vanced and  what  fields  it  involves.  For  example,  one  patient 
may  know  he  is  in  an  institution  but  be  unable  to  give  his  age ; 
another  may  not  know  the  day  of  the  week  or  the  month  of  the 
year;  and  still  another  may  have  lost  all  recollection  of  his 
family  and  previous  associates. 

Slight  degrees  of  disorientation,  especially  mistakes  regarding 
time,  are  encountered  in  almost  all  psychoses.  The  fact  that 
some  patients  do  not  know  the  day  or  the  date  is  of  no  diag- 
nostic significance,  provided  their  orientation  in  other  directions 
is  good.  A  much  more  serious  manifestation  is  complete  dis- 
orientation. The  latter  occurs  in  all  acute  psychoses  with 
marked  confusion,  such  as  epileptoid  states,  acute  hallucinatory 
states,  and  febrile  and  alcoholic  delirium,  and  in  states  of  deep 
dementia  like  idiocy  and  the  final  stages  of  paresis  and  dete- 
rioration. 

Before  we  proceed  the  term  "confusion"  requires  some  eluci- 
dation. In  psychiatry  it  is  used  to  represent  a  state  of  obscured 
consciousness,  in  which  partial  or  complete  disorientation  exists 
regarding  time,  space,  surroundings  and  self.  The  degree  of 
disorientation  usually   parallels  the  depth  of  the  disorder  of 


134     THE  UNSOUND  MIND  AND  THE  LAW 

consciousness,  although  instances  do  occur  in  which  orientation 
remains  intact  notwithstanding  the  existence  of  pronounced  dis- 
turbances of  consciousness.  Applied  in  this  strict  sense,  the 
notion  of  "confusion"  acquires  extraordinary  value  for  diag- 
nosis and  prognosis,  and  for  this  reason  in  all  acute  psychoses 
it  is  most  important  to  ascertain  whether  and.  in  which  domains 
disorientation  exists,  whether  it  is  combined  with  any  disorder 
of  consciousness  and  whether  sense  deceptions  and  delusions  are 
present. 

It  is  precisely  the  relationship  that  exists  between  outward 
disorientation  and  the  contents  of  the  delusions  that  is  of  essen- 
tial prognostic  significance.  The  more  senseless  the  delusions 
and  the  more  complete  the  orientation  the  more  unfavorable 
will  be  the  prognosis.  The  more  unconnected  the  delusions  and 
the  greater  the  disorientation  the  better  will  be  the  prognosis. 
These  premises  have  great  psychiatric  importance.  It  will  be 
easily  understood  why  a  mental  disease  in  which  delusions  de- 
velop notwithstanding  the  preservation  of  the  power  of  orienta- 
tion must  be  much  more  serious  than  a  psychosis  in  which  the 
delusions  are  the  natural  outcome  of  a  lack  of  orientation.  In 
the  first  instance  there  exists  a  control  which  enables  the  patient 
to  recognize  the  senselessness  of  his  delusions,  the  unfavorable 
factor  being  that  this  control,  i.  e.,  the  power  of  orientation,  is 
not  exercised.  In  the  latter  instance  the  delusions  arise  essen- 
tially in  consequence  of  the  disorientation.  "With  a  return  of 
the  power  of  orientation  the  control  again  becomes  operative 
and  the  delusions  disappear  just  as  logically  and  naturally  as 
they  arose.  A  priori  it  is  incomprehensible  how  delusions  can 
arise  in  the  presence  of  complete  orientation ;  the  fact  that  they 
do  so  arise  constitutes  the  gravity  of  the  conditions.  The  rela- 
tions that  obtain  between  orientation  and  the  psychoses  can  best 
be  explained  by  means  of  examples.  An  instance  frequently 
encountered  is  the  following: 

A  person  who  under  certain  extraordinary  conditions  has 
committed  an  act  of  violence  is  placed  under  psychiatric  ob- 
servation. The  examiner  finds  him  with  face  suffused  and  per- 
spiring, persistently  fumbling  with  his  bed  clothes,  shaking  the 
blankets,  tugging  at  the  sheets,  wiping  them,  getting  out  of  bed 
and  stamping  upon  the  ground  as  though  he  were  crushing 
something  with  his  feet.     Upon  being  questioned  the  patient  in- 


THE  EXAMINATION  OF  THE  INSANE     135 

sists  his  bed  is  full  of  insects  and  that  they  are  crawling  all  over 
his  body.  His  movements  are  abrupt  and  unsteady.  His  hands 
and  feet  tremble,  his  gait  is  stumbling  and  swaying.  He  answers 
questions  only  when  addressed  in  a  loud  tone.  He  states  his 
name  and  occupation  correctly,  but  gives  incorrect  answers  to 
questions  concerning  his  place  of  birth,  his  age,  the  season  of  the 
year,  the  date  and  the  day.  He  believes  he  is  in  the  bedroom  of 
his  own  home,  and  the  strange  surroundings  of  the  hospital  leave 
him  entirely  unaffected. 

Hence,  he  shows  the  following  symptoms :  Marked  motor  un- 
rest, sense  deceptions,  pronounced  tremor,  complete  disorienta- 
tion as  to  time,  space  and  surroundings  and  partial  disorienta- 
tion in  regard  to  his  own  person.  All  this  constitutes  the 
typical  picture  of  an  alcoholic  delirium.  The  act  of  violence  he 
has  committed  must,  therefore,  be  looked  upon  as  the  deed  of  a 
chronic  alcoholic  lacking  in  free  determination  and  in  responsi- 
bility. 

Another  patient  is  found  in  bed,  her  face  wearing  an  expres- 
sion of  deepest  depression  and  her  forehead  showing  the  wrinkles 
and  furrows  characteristic  of  grief.  Her  hands  are  clasped  and 
she  whispers  words  of  prayer.  Her  pupils  are  noticeably  large, 
her  facial  expression  is  ecstatic,  one  of  dreamy  suffering.  Occa- 
sionally a  beatific  smile  passes  over  her  countenance;  then  she 
stares  searchingly  at  a  certain  point  of  the  ceiling.  Being  ques- 
tioned, she  answers  she  has  seen  God's  angels  hovering  above 
her.  Next  she  begs  that  she  may  be  allowed  to  go  home.  She 
asks  to  be  enlightened  as  to  what  is  to  be  done  with  her.  She 
claims  the  air  is  heavy  with  the  smell  of  sulphur;  people  who 
were  at  her  bedside  had  ridiculed  her,  had  scolded  her  and  she 
wants  such  doings  ended.  In  regard  to  her  own  self  she  gives 
perfectly  clear  information;  on  the  other  hand,  she  is  com- 
pletely disoriented  in  regard  to  time,  place  and  surroundings. 
She  is  unable  to  tell  the  day,  date  or  season ;  she  does  not  know 
she  is  in  a  sanatorium,  etc.  The  first  impression  is  that  this 
patient  is  suffering  from  a  state  of  depression.  But  the  dreamy 
expression  of  her  face,  the  complete  disorientation  as  to  time  and 
place,  the  passing  beatific  mood  arising  in  the  midst  of  her  emo- 
tional depression,  as  well  as  the  sense  deceptions  (visions  of 
angels,  hallucinations  of  smell  and  hearing)  i  leave  but  little 
doubt  that  we  are  dealing  with  an  epileptic  twilight  state  of  a 


136     THE  UNSOUND  MIND  AND  THE  LAW 

depressive  character.  That  such  persons,  when  dominated  by- 
sense  deceptions  of  an  irritating  nature,  may  become  dangerous 
to  themselves  and  to  their  surroundings,  has  already  been  men- 
tioned. 

During  the  first  psychic  examination  a  patient  will  occasion- 
ally create  the  impression  of  complete  disorientation,  while  a 
subsequent  test  will  show  him  to  be  very  well  oriented.  If  this 
change  from  disorientation  to  orientation  takes  place  within  a 
very  few  hours,  although  nothing  else  in  the  patient's  condition 
has  been  altered,  we  are  prone  to  assume  he  is  wilfully  trying  to 
deceive  the  examiner.  The  assumption  becomes  all  the  more 
plausible  when  the  patient's  erroneous  responses  to  questions  are 
given  quickly  and  without  hesitancy,  quite  as  though  they  had 
been  premeditated.  Nevertheless  the  patient  should  not  be 
looked  upon  as  a  simulant,  for  under  similar  conditions  the  simu- 
lator would  be  persistent  and  would  always  give  the  same  pre- 
meditated reply  to  repeated  similar  tests.  Under  no  circum- 
stances would  he  first  answer  a  question  erroneously  and  later 
reply  correctly  to  the  same  query.  It  is  above  all  the  incon- 
gruity of  responses  that  constitutes  the  symptom  of  disease  in 
cases  of  the  sort  under  consideration. 

An  accurate  orientation  test  is  of  decisive  diagnostic  value  in 
two  psychoses  which,  notwithstanding  certain  fundamental  dif- 
ferences, are  often  confounded.  These  are  acute  hallucinatory 
confusion  and  dementia  praacox  paranoides.  The  former  is  a 
psychosis  that  terminates  in  recovery  or  death;  the  latter  a 
chronic  degenerative  process,  usually  leading  to  complete  de- 
terioration. As  an  example  of  a  case  of  acute  hallucinatory 
confusion,  let  us  take  a  woman  who  presents  the  following 
picture : 

The  first  impression  is  that  of  a  stuporous,  barely  conscious, 
insane  individual.  More  detailed  observation  shows  her  face  to 
be  distorted  and  drawn,  her  expression  apprehensive  and  timid, 
her  hair  undone  and  hanging  disheveled  over  face  and  shoulders. 
The  entire  state  of  the  patient  is  one  of  marked  apprehensive 
restlessness.  She  appears  to  be  defending  herself  against  at- 
tacks; with  hands  and  feet  she  blindly  beats  the  air;  she  kicks 
things  away  from  her,  wounds  herself  repeatedly  in  her  sense- 
less efforts  and  exposes  her  body  without  the  least  feeling  of 
shame.    Her  speech  is  unconnected  and  dragging,  and  no  definite 


THE  EXAMINATION  OF  THE  INSANE     137 

information  can  be  obtained  from  her.  The  picture  is  made  up 
of  a  pronounced  clouding  of  consciousness  with  complete  dis- 
orientation, persistent  apprehensive  restlessness  linked  with  inco- 
ordination, and  a  facial  expression  distinctly  indicative  of  seri- 
ous disease  and  semi-stupor.  Acute  hallucinatory  confusion  is 
of  frequent  occurrence,  but  must  be  classed  among  the  curable 
psychoses. 

The  paranoid  form  of  dementia  prascox  resembles  hallucina- 
tory confusion  in  many  ways.  Let  us  consider  the  following 
typical  case,  that  of  a  young  man  in  a  state  of  pronounced  ap- 
prehensive excitement.  The  facial  expression  is  one  of  great 
fear  and  horror,  and  the  patient  is  manifestly  dominated  by 
auditory  deceptions  of  an  appalling  nature.  Suddenly  he  jumps 
up,  listens  apprehensively,  makes  an  endeavor  to  escape,  then 
suddenly  becomes  immobile  as  though  riveted  by  fear ;  he  sinks 
back  into  bed  and  cries  aloud  for  help,  fearing  he  is  to  be  at- 
tacked and  torn  to  pieces.  Thus  the  patient  is  in  a  state  of 
constant  unrest  and  anxious  excitement;  nevertheless  all  his 
movements  are  purposeful  and  coordinate.  His  facial  expres- 
sion bears  no  mark  of  stupor  or  dulness.  On  the  contrary,  he  is 
alert  and  constantly  watches  everything  about  him  in  an  ap- 
prehensive and  distrustful  manner.  The  patient's  orientation, 
notwithstanding  his  great  excitement  and  the  existing  sense  de- 
ceptions and  delusions,  can  be  easily  tested.  The  test  demon- 
strates the  patient  to  be  almost  completely  oriented  in  regard  to 
his  own  person  and  in  regard  to  time,  place  and  surroundings. 
Thus  we  see  that,  notwithstanding  the  concordance  of  certain 
symptoms,  the  picture  of  disease  presented  by  this  patient  dif- 
fers materially  from  the  one  presented  by  the  patient  suffering 
from  hallucinatory  confusion.  In  the  present  instance  orienta- 
tion is  completely  preserved,  in  the  other  it  is  entirely  lost.  In 
the  one  the  movements  are  purposeful,  in  the  other  they  are 
unbridled  and  aimless.  In  the  one,  behavior  is  orderly  and, 
considering  the  hallucinatory  premise,  logical,  while  in  the  other 
the  conduct  is  entirely  disordered.  Moreover,  the  marked  de- 
gree of  orientation  that  is  present  in  spite  of  the  mass  of  hallu- 
cinations and  delusions,  shows  us  that  in  this  case  we  are  deal- 
ing not  with  a  prognostically  favorable  hallucinatory  confusion, 
but  with  a  degenerative  process  which  will  end  in  chronic  de- 
terioration. 


138     THE  UNSOUND  MIND  AND  THE  LAW 

After  having  determined  the  degree  of  a  patient 's  orientation, 
the  physician  should  obtain  from  the  patient  himself  a  precise 
anamnesis  of  his  previous  life,  as  well  as  of  the  period  immedi- 
ately antedating  the  development  of  the  psychosis.  In  this  man- 
ner new  facts  of  importance  regarding  the  previous  history  are 
often  obtained,  facts  which  have  been  overlooked  or  purposely 
concealed  by  the  relatives.  Thus  also  we  will  often  be  able  to 
clear  up  certain  points  of  diagnostic  importance,  as  for  instance 
the  patient's  subjective  feeling  of  illness,  his  insight  into  his  own 
condition,  his  memory,  his  power  of  judgment  and  his  general 
intelligence.  All  this,  of  course,  cannot  be  done  if  the  physician 
is  unable  to  gain  the  confidence  of  the  patient. 

If  the  patient  looks  upon  the  physician  as  a  sort  of  legal 
inquisitor  he  will  not  be  likely  to  disclose  his  innermost  thoughts 
and  feelings.  Many  insane  persons  are  most  suspicious  and  un- 
communicative, and  they  must  be  convinced  of  the  physician's 
desire  to  help  them  before  they  will  talk.  Frequently  it  is  most 
difficult  for  the  physician  to  place  himself  upon  the  thought  level 
of  an  uneducated  and  unintelligent  patient.  The  latter,  how- 
ever, is  often  quick  to  notice  whether  the  physician  understands 
him  and  sympathizes  with  him  or  not.  Many  patients,  there- 
fore, will  remain  morose  and  distrustful  simply  because  they 
have  no  confidence  in  the  physician  and,  as  they  do  not  respond 
to  tests,  no  correct  impression  of  their  true  intellectual  state  can 
be  obtained.  In  forensic  cases  it  is,  of  course,  doubly  important 
that  an  accurate  anamnesis  be  obtained  from  the  patient  him- 
self and  that  all  statements  made  by  the  patient  should  be  re- 
corded. 

Analysis  and  diagnostic  application  of  the  patient's  state- 
ments are  possible  only  after  it  has  been  determined  whether 
sense  deceptions  are  present  or  absent.  It  need  hardly  be  said 
that  the  statements  made  by  patients  in  giving  their  previous 
history  must  be  corroborated  before  they  can  be  accepted  as 
facts.  This  is  so  not  only  because  in  many  patients  there  may 
exist  a  predetermined  intent  to  deceive,  but  because  we  must 
always  count  upon  the  possibility  that  the  patient  is  being  in- 
fluenced by  sense  deceptions,  which  efface  the  dividing  line  be- 
tween imagination  and  reality  and  are  of  the  greatest  impor- 
tance not  only  in  relation  to  the  actual  development  of  the  psy- 


THE  EXAMINATION  OF  THE  INSANE     139 

choses,  but  also  in  relation  to  the  history  the  patient  himself 
gives. 

In  a  general  way  we  may  divide  hallucinatory  patients  into 
those  who  speak  of  their  sense  deceptions  and  who  when  asked 
will  give  information  in  regard  to  them,  and  those  who  dissimu- 
late any  sense  deceptions  they  may  have.  In  both  instances  the 
patients  believe  their  hallucinations  to  be  actual  occurrences; 
they  do  not  realize  that  they  themselves  are  a  prey  to  sense  de- 
ceptions. It  is  precisely  this  inability  to  differentiate  between 
imagination  and  reality  that  constitutes  the  pathological  char- 
acter of  those  sense  aberrations.  Were  these  hallucinations  rec- 
ognized by  the  patient  as  pathological  they  could  not  constitute 
the  basis  for  delusions.  Certain  patients,  however,  have  learned 
that  they  will  be  derided  and  even  scolded  if  they  speak  of  the 
voices  they  have  heard,  things  they  have  seen,  etc.  This  is 
probably  the  chief  reason  why  they  either  conceal  their  hal- 
lucinations or  else  show  great  reluctance  in  giving  information 
concerning  them. 

In  those  who  dissimulate  their  sense  deceptions  we  are  obliged 
to  rely  essentially  upon  the  objective  signs  which  have  already 
been  mentioned.  In  general  it  will  not  be  difficult  for  an  ex- 
pert psychiatrist  to  determine  the  existence  of  sense  deceptions, 
even  when  the  patient  endeavors  to  conceal  them  or  when  he 
cannot  or  will  not  talk. 

In  the  majority  of  instances  the  patients  voluntarily  disclose 
their  deceptions,  or,  when  questioned,  they  at  once  admit  having 
them.  Occasionally  the  best  means  of  obtaining  an  admission 
from  a  patient  who  seems  to  be  suffering  from  hallucinations  is 
to  assert  directly  that  he  hears  voices,  sees  figures,  etc.  Dissimu- 
lation is  particularly  frequent  in  paranoiacs,  but  even  they,  when 
asked  directly,  "What  are  the  voices  now  saying?"  or  "What  fig- 
ures do  you  now  see  ?  "  will  usually  at  once  give  an  artless  reply. 
Strange  to  say,  all  hallucinants  at  once  understand  the  meaning 
of  the  words  "voices"  or  "figures."  Consequently  when  a  pa- 
tient answers,  "I  hear  no  voices,"  this  negative  is  useful;  be- 
cause if  a  patient  has  no  hallucinations,  he  does  not  know  just 
what  is  meant  by  "voices"  and  "figures"  and  may  ask  for  an 
explanation,  but  he  certainly  will  not  respond  promptly  with 
' '  I  hear  no  voices, ""  I  see  no  figures. ' ' 

Similarly  the  presence  of  delusions,  ideas  of  grandeur  and,  of 


140     THE  UNSOUND  MIND  AND  THE  LAW 

persecution  will  often  be  acknowledged  without  delay  when  the 
patient  is  directly  accused  of  having  them.  As  a  matter  of 
course,  every  examination  of  a  patient  suffering  from  mental 
disease  presupposes  that  the  examiner  understands  precisely 
what  constitutes  a  sense  deception,  under  what  different  forms 
it  may  exist  and  what  may  be  its  diagnostic  value.  Since  the 
time  of  Esquirol  sense  deceptions  have  been  artificially,  yet 
practically,  divided  into  illusions  and  hallucinations. 

Illusions  are  actual  perceptions,  which,  however,  enter  the 
patient's  field  of  consciousness  in  a  falsified  form.  Hallucina- 
tions are  perceptions  for  which  there  is  no  external  basis. 
Theoretically  hallucinations  are  of  purely  central  origin,  there 
being  no  productive  stimulus  discoverable  in  any  part  of  the 
sensory  conducting  tracts.  In  many  instances,  however,  it  is 
impossible,  even  by  means  of  the  most  exact  methods  of  examina- 
tion, to  determine  whether  some  pathological  process,  acting  for 
instance  upon  the  middle  ear,  upon  the  mucous  membrane  of  the 
nose,  mouth  and  pharynx,  or  upon  the  retina,  is  not  after  all  the 
actual  cause  of  the  sense  deceptions.  Illusions  in  themselves  are 
not  pathological  and  every  person,  particularly  one  who  is  en- 
dowed with  a  vivid  imagination,  may  occasionally  be  subject  to 
them.  Hallucinations  on  the  other  hand  are  in  all  instances  a 
sign  of  existing  mental  disorder.  Any  correction  of  an  hal- 
lucination by  means  of  an  actual  sensory  perception  is  entirely 
out  of  the  question.  A  person  of  sound  mind  can  recognize  his 
error,  can  correct  his  sense  deception;  but  this  does  not  hold 
true  in  the  person  of  unsound  mind.  He  lacks  control  of  his 
sensory  apparatus  and,  therefore,  cannot  be  convinced  of  his 
error.  Illusions  may  even  be  produced  by  those  errors  that  are 
dependent  upon  inadequate  and  incomplete  sense  impressions. 
In  persons  of  sound  mind,  however,  the  error  does  not  persist 
for  any  length  of  time,  for  by  means  of  greater  concentration  of 
attention  or  by  means  of  more  intensified  fixation  of  the  object 
in  question,  partly  also  through  the  aid  of  other  senses,  they 
will  be  able  to  control  and  rectify  their  judgment.  Involun- 
tarily we  regard  more  closely  any  object  that  has  produced  a 
sense  deception.  Where  the  light  is  poor  we  endeavor  to  sup- 
plement the  visual  impression  by  our  sense  of  touch.  The  latter 
again  we  often  control  by  our  sense  of  hearing,  just  as  we  con- 
trol this  by  our  sense  of  sight.    If  in  the  dark  we  believe  we  see 


THE  EXAMINATION  OF  THE  INSANE     141 

a  wagon  approaching,  we  listen  for  the  sound  the  revolving 
wheels  should  make ;  if  on  the  other  hand  we  hear  the  sound  of 
wheels,  we  carefully  look  around  to  see  what  is  causing  it.  More 
persistent  illusions  are  dependent  upon  an  inadequate  experi- 
ence with  the  world  about  us  (the  child,  for  instance,  believes 
the  moon  to  be  within  reaching  distance  and  stretches  out  its 
arms  to  touch  it),  upon  lack  of  discrimination,  upon  precon- 
ceived opinions,  and  upon  concentrated  emotion,  especially  dur- 
ing intense  expectancy,  when  we  believe,  see  or  hear  that  which 
we  expect  to  see  or  hear. 

The  production  of  illusions  is  encouraged  particularly  by  the 
clouding  of  consciousness  that  is  present  in  alcoholic  intoxica- 
tion, in  narcosis  or  in  fever,  but  they  may  also  occur  where  con- 
sciousness is  completely  unobscured. 

Still  another  point  merits  attention.  Every  person  has  a 
tendency  to  supplement  an  imperfect  sensory  perception  in  his 
own  peculiar  way.  It  is  this  fact  that  is  the  cause  of  those  ex- 
traordinary differences  in  the  comprehension  of  one  and  the  same 
occurrence  so  frequently  encountered  and  so  often  manifested 
in  the  testimony  given  by  different  witnesses  in  court.  Every 
physician  must  have  observed  and  been  astonished  at  the  con- 
tradictions manifested  by  excited  but  particularly  intelligent 
patients,  when,  at  the  end  of  a  consultation,  they  are  asked  to 
repeat  the  substance  of  the  explanation  and  advice  given  to 
them.  In  such  instances  we  speak  of  illusions  of  memory.  These, 
occurring  as  they  do  in  perfectly  healthy  persons  under  the 
influence  of  emotion  or  distraction,  are  all  the  more  likely  to 
be  present  when  fatigue,  disease,  etc.,  have  affected  the  functions 
of  the  brain. 

Illusions  become  pathological  only  when  the  patient  is  unable 
to  free  himself  from  the  deceptions  involved.  Soon  he  makes  no 
effort  to  overcome  them  and  he  proves  refractory  to  all  attempts 
on  the  part  of  others  to  correct  them.  Most  curious  instances  of 
this  nature  are  likely  to  be  encountered.  Many  a  mentally  un- 
sound person  cannot  be  dissuaded  from  believing  all  noises  to  be 
the  footfalls  of  his  persecutors,  flower  beds  to  be  graves  in  a 
cemetery,  the  movements  that  take  place  in  his  stomach  after  a 
meal  to  be  manifestations  of  life  in  the  animals  whose  flesh  he 
has  eaten. 

While  illusions,  as  we  have  explained,  result  from  a  miscon- 


142     THE  UNSOUND  MIND  AND  THE  LAW 

ception  of  actual  sense  perceptions,  hallucinations  as  a  rule  are 
dependent  upon  the  production  of  cortical  excitation  through 
which  the  memory  pictures  of  a  previous  excitation  caused  by  a 
real  object  is  revived,  but  this  time  without  the  presence  of  any 
actual  object.  This  is  why  recollection  plays  a  far  greater  role 
in  hallucinations  than  in  illusions. 

Esquirol  characterizes  hallucinations  as  concepts  and  pictures 
that  have  been  reproduced  by  the  memory,  a  process  like  that 
which  takes  place  in  a  dream,  in  which,  as  we  well  know,  the 
products  of  the  imagination  are  believed  to  be  real  occurrences. 
The  sensory  organs  themselves  are  entirely  irrelevant  in  the 
production  of  hallucinated  sense  perceptions,  for  they  do  not 
transmit  the  hallucinatory  processes  any  more  than  they  inhibit 
them.  Hallucinations  occur  in  the  brightest  daylight  as  well  as 
in  the  deepest  darkness.  Every  psychiatrist  has  observed  in- 
stances of  hallucinations  of  sight  in  blind  people  or  of  hearing 
in  deaf  people.  In  such  instances  it  is  absolutely  certain  that 
the  hallucinations  cannot  have  been  transmitted  by  the  senses. 
Even  when  a  patient  has  been  given  to  understand  that  because 
of  his  blindness  or  deafness  the  figures  he  has  seen  or  the  voices 
he  has  heard  could  not  have  any  real  existence,  he  will  persis- 
tently maintain  that  his  statements  are  correct. 

A  few  points  that  are  of  particular  importance  in  the  estima- 
tion of  doubtful  states  of  mental  disorder  and  in  the  forensic 
determination  of  responsibility  require  more  detailed  consid- 
eration. 

1.      ILLUSIONS 

By  far  the  most  common  illusions  are  those  of  sight.  They 
are  more  likely  to  occur  in  patients  suffering  from  acute  dis- 
eases in  whom  marked  excitement  is  associated  with  a  certain 
degree  of  obscured  consciousness.  Illusions  of  sight  are  almost 
always,  therefore,  a  sign  of  disordered  consciousness.  They  con- 
stitute the  characteristic  and  often  the  only  symptom  of  dis- 
ordered mental  activity  in  cases  of  fever  delirium  (typhoid, 
tuberculosis,  etc.).  In  addition  they  are  encountered  in  the 
excited  states  of  epilepsy  and  alcoholism  and  they  are  of  special 
importance  in  delirium  tremens,  in  which  they  may  with  ease 
be  produced  experimentally  at  any  time.     If  a  patient  in  alco- 


THE  EXAMINATION  OF  THE  INSANE     143 

holic  delirium  be  shown  a  smudge  upon  the  wall  and  asked  to 
tell  what  it  is,  he  will  in  the  majority  of  instances  mistake  it  for 
hugs,  spiders,  mice,  etc.  The  illusions  of  sight  that  are  present 
in  alcoholic  delirium  can  be  demonstrated  most  easily  by  showing 
the  patient  some  simple  picture  and  asking  him  to  explain  it. 
The  interpretation  given  will  be  of  the  most  ridiculous  kind.  At 
this  point,  however,  I  would  recall  the  fact  that  there  can  be  a 
question  of  pathological  sense  deception  only  after  it  has  been 
shown  that  the  organs  of  special  sense  themselves  are  not  so 
affected  organically  as  to  give  rise  to  an  erroneous  interpretation, 
and  only  when  such  erroneous  interpretation  of  sensory  percep- 
tions can  no  longer  be  corrected. 

A  special  kind  of  visual  illusion  is  the  mistaking  or  confound- 
ing of  persons  which  is  encountered  as  a  permanent  or  trans- 
itory manifestation  in  nearly  all  psychoses.  Patients  in  whom 
this  symptom  is  present  mistake  their  hospital  associates  for 
relatives  or  former  acquaintances,  while  upon  the  other  hand 
they  often  fail  to  recognize  their  relatives,  but  maintain  that  the 
latter  are  merely  masquerading  or  disguised  or  have  assumed 
the  familiar  facial  expression  for  the  purpose  of  deception.  Let 
us  emphasize  the  fact  that  in  these  eases  there  can  be  no  question 
of  those  mistakes  of  recognition  which  occur  in  healthy  indi- 
viduals as  a  result  of  marked  similarity  in  appearance ;  for  the 
patients  of  whom  we  are  speaking  deceive  themselves  even  where 
there  cannot  be  the  slightest  question  of  any  resemblance  or  of 
the  person's  identity.  It  is  this  self-deception  that  constitutes 
the  manifestation  of  disease. 

Maniacal  patients,  when  at  the  height  of  their  exaltation,  often 
make  mistakes  in  the  recognition  of  persons,  but  they  quickly 
correct  these  when  their  attentiveness  has  been  stimulated.  The 
same  statement  applies  to  patients  in  alcoholic  delirium.  In 
these  cases  the  illusionary  mistaking  of  persons  is  essentially  the 
result  of  diminished  comprehension  and  attentiveness.  This  con- 
founding of  persons,  as  well  as  most  other  illusions  of  sight  in 
acute  states  of  excitement  or  confusion,  is  a  symptom  of  little 
prognostic  significance.  But  where  it  is  persistently  present  in 
patients  who  are  collected  and  quiet,  and  where  the  same  delu- 
sional mistakes  are  always  associated  with  the  same  persons,  it  is 
usually  of  adverse  significance  and  constitutes  part  of  a  para- 
noiac symptom  complex. 


144     THE  UNSOUND  MIND  AND  THE  LAW 

Of  great  diagnostic  and  prognostic  significance  are  illusions  of 
hearing.  Thus,  for  instance,  the  favorable  prognosis  of  a  simple 
state  of  depression  may  be  completely  altered  by  the  superven- 
tion of  illusions  of  hearing.  A  patient  who  interprets  the  ham- 
mering of  steam  in  the  radiators  as  alarming  threats  of  his 
persecutors  suffers  from  an  illusion  which  is  directly  and  char- 
acteristically related  to  his  false  beliefs.  Where  we  encounter 
symptoms  only  of  a  melancholia  or  of  a  mental  depression,  such 
as  restlessness,  sleeplessness,  sadness  and  self-reproaches  on  ac- 
count of  minor  omissions — the  patient  otherwise  being  fully 
oriented  and  collected — we  are  always  warranted  in  forming  a 
good  prognosis.  If,  however,  the  patient  suddenly  becomes  sus- 
picious, if  he  believes  all  conversations  held  in  his  presence  to 
refer  to  himself  and  contain  insinuations  and  accusations  against 
his  character,  etc.,  we  may  be  certain  that  we  are  dealing  with 
an  incipient  paranoia,  and  that  entirely  isolated  illusions  that 
have  arisen  in  one  sensory  field  will  recur  with  steadily  aug- 
menting frequency  and  will  soon  be  followed  by  hallucinations 
of  hearing  and  an  ineffaceable  fixed  delusion.  Then  the  pri- 
marily favorable  diagnosis  will  have  to  be  dropped  and  a  grave 
one  substituted,  because  isolated  auditory  hallucinations  often 
occur  as  an  initial  symptom  of  paranoia.  Auditory  hallucina- 
tions that  are  not  isolated  but  are  combined  with  visual  or  other 
sense  illusions  occur  in  other  forms  of  mental  disease,  as  in 
alcoholic  delirium  and  melancholia  when  at  its  height,  in  which 
the  diagnosis  can  present  no  difficulty. 

Illusions  of  the  remaining  senses  can  hardly  be  differentiated 
from  hallucinations  affecting  these  same  senses,  hence  it  will  be 
best  to  consider  these  disturbances  together.  There  can  be  no 
question  that  the  distinction  that  may  be  more  or  less  precisely 
made  between  illusions  and  hallucinations  affecting  the  visual 
and  auditory  senses  can  be  made  to  apply  only  with  the  great- 
est difficulty  to  corresponding  disturbances  of  the  senses  of 
smell,  taste  and  touch.  To  sum  up  the  situation,  it  may  be  said 
that  while  the  presence  of  an  hallucination  is  unquestionably 
an  evidence  of  mental  disorder,  the  occurrence  of  an  illusion 
does  not  necessarily  warrant  the  assumption  of  the  existence 
of  a  pathological  mental  state.  A  mentally  healthy  person  who 
has  had  an  illusion  will  always  realize  his  mistake  or  permit  him- 
self to  be  corrected,  but  the  mentally  disordered  person  can 


THE  EXAMINATION  OF  THE  INSANE     145 

never  be  convinced  of  his  error.  Moreover,  the  illusions  of 
healthy  persons  usually  occur  but  singly  and  transitorily  under 
conditions  that  vividly  excite  the  imagination  and  the  emotions, 
or  when,  as  in  half-sleep  or  states  of  exhaustion,  sensory  per- 
ceptions are  incomplete.  On  the  other  hand,  illusions  in  per- 
sons who  are  mentally  disordered  occur  at  any  period  of  the 
day,  even  when  such  persons  are  not  excited  or  are  not  in  any 
other  way  psychically  predisposed.  Moreover,  their  illusions  do 
not  occur  singly  and  transitorily,  but  in  quantities,  and  consti- 
tute a  permanent  component  of  their  being.  The  most  im- 
portant differentiating  characteristic  by  far,  however,  is  the  fact 
that  the  illusions  of  mentally  healthy  persons,  no  matter  how 
extraordinary  they  may  be,  never  bear  any  relation  to  delu- 
sional notions,  as  they  always  do  in  those  who  are  mentally 
diseased. 

2.      HALLUCINATIONS 

Hallucinations  of  hearing  are  the  most  common  of  all  sense 
deceptions.  They  may  occur  in  almost  all  psychoses,  and  the 
patient  usually  characterizes  them  as  ''voices."  They  manifest 
themselves  either  in  the  form  of  so-called  elementary  sense  de- 
ceptions like  simple  noises,  buzzing,  roaring,  whistling,  crackling 
or  ringing,  or  else  they  occur  as  articulate  words,  entire  sen- 
tences or  complete  connected  conversations.  Some  patients  hal- 
lucinate only  upon  one  ear,  but  the  majority  upon  both.  Occa- 
sionally the  hallucinations  of  the  one  ear  are  of  an  entirely  dif- 
ferent nature  from  those  of  the  other.  Magnan  refers  to  a  pa- 
tient who  heard  disagreeable,  scolding  voices  with  the  right  ear, 
while  with  the  left  he  heard  only  complimentary  ones.  At  one 
time  the  voices  may  be  low  and  whispering,  at  another  loud  and 
sonorous.  Some  patients  hear  two  or  three  voices  at  once,  while 
others  hear  an  entire  Babel  of  voices  as  though  hundreds  of 
people  were  talking  simultaneously,  with  here  and  there  a  voice 
being  raised  above  the  others  so  single  words  can  be  understood. 
Some  patients  clearly  differentiate  the  voices  of  men,  women  and 
children.  Occasionally  the  voices  heard  are  droningly  monoto- 
nous, the  same  stereotyped  words  being  repeated  day  after  day 
for  weeks.  In  other  cases  the  tone  of  the  voices  is  constantly 
changing  and  the  context  of  the  phrases  is  variable.  A  polylingual 


146     THE  UNSOUND  MIND  AND  THE  LAW 

patient  will  hallucinate  in  various  languages.  Patients  localize 
the  voices  differently.  They  hear  them  as  corning  from  the  ceil- 
ing, from  the  cellar,  from  the  stove,  from  the  closet,  or  from  out 
of  doors.  Some  believe  the  voices  to  come  from  their  own  bodies, 
from  the  head  or  abdomen. 

Most  frequently  the  hallucinations  of  hearing  are  expressive 
of  contempt  or  contain  threats  and  accusations.  Other  voices 
convey  important  secret  commands  or  divine  missions,  this  oc- 
curring usually  in  patients  in  whom  ideas  of  grandeur  are  either 
present  or  developing.  Such  patients  converse  with  God,  with 
the  angels,  with  the  Pope,  with  kings  and  superiors  of  all  kinds. 
They  hear  they  have  been  appointed  to  important  missions,  even 
to  the  rulership  of  the  world,  and  their  facial  traits  assume  a 
correspondingly  glorified  expression.  Other  patients  are  tor- 
mented for  weeks  by  the  most  distressing  auditory  hallucina- 
tions. From  all  sides  they  hear  sarcastic,  contemptuous,  ac- 
cusing voices.  Their  entire  life  is  befouled  by  calumnies;  they 
are  accused  of  infamous  acts  and  are  summoned  into  court. 
Occasionally  voices  arise  in  their  defense  and  speak  well  of  tliein, 
but  ultimately  the  catastrophe  occurs  and  they  are  condemned. 
Under  the  influence  of  their  hallucinations  of  sight  and  hearing, 
everything  becomes  dramatically  vivid  and  realistic.  Word  suc- 
ceeds word,  sentence  follows  sentence.  The  patient  becomes  the 
inexorable  victim  of  his  hallucinations.  These,  of  course,  can 
originate  only  in  the  conceptual  sphere  of  the  patient.  If,  for 
instance,  he  knows  nothing  of  the  existence  of  a  Pope,  he  cannot 
hear  voices  which  bestow  upon  him  the  Papal  chair.  No  matter 
how  nonsensical  the  hallucinations  may  be,  they  can  be  made  up 
only  of  things  which  previously  have  occupied  the  patient's 
thoughts.  By  means  of  false  association  of  ideas  that  have  al- 
ready been  present,  however,  they  make  the  patient  believe 
things  to  be  real  which  actually  are  imaginary.  Never  does  the 
patient  receive  new  disclosures  that  go  beyond  his  previous  con- 
ceptual capacity.  A  noteworthy  feature  of  all  auditory  hal- 
lucinations is  the  extraordinary  sensuous  distinctness  and  plas- 
ticity that  enable  them  to  exert  such  marked  and  often  irre- 
sistible power  over  the  patient,  and  to  stand  out  above  all  the 
real  voices  that  reach  them  through  people,  books  or  newspapers. 
A  special  form  of  auditory  hallucinations  is  that  in  which  the 
acoustic  verbal  images  of  the  thought  itself  are  projected  out- 


THE  EXAMINATION  OP  THE  INSANE     147 

side  in  such  a  way  that  whatever  the  subject  thinks  he  hears  re- 
peated in  speech.  This  echo  des  pensees  not  only  repeats  the 
patients'  thoughts,  but  announces  their  future  actions.  Sim- 
ilarly, while  they  are  reading  or  writing,  they  hear  the  voices 
accurately  repeat  every  word  and  sentence.  This  symptom  of 
thought  repetition  is  not  very  frequent.  Patients  so  afflicted 
call  it  ' '  stealing  my  thoughts  "  or  "  draining  my  thoughts. ' '  The 
practical  diagnostic  and  prognostic  value  of  this  symptom  is  that 
it  occurs  almost  exclusively  in  paranoid  states  with  an  un- 
favorable course. 

Hallucinations  of  sight,  which  are  not  so  frequent,  and  are 
often  associated  with  auditory  hallucinations,  may  also  be  di- 
vided into  single  and  complex  sense  deceptions.  Elementary 
visual  hallucinations  are  made  up  of  sparks,  flames  and  figura- 
tions, fiery  stars,  colored  wreaths  and  colored  rings.  In  other 
cases  the  patients  see  menacing  images  and  dangerous  animals. 
Some  see  entire  groups  of  people,  or  spectacles  in  which  the 
various  figures  appear,  disappear  and  replace  one  another.  All 
of  these  things,  of  course,  occur  also  in  the  dreams  of  those  who 
are  mentally  well;  but  the  patient  who  is  awake  believes  his 
"dream" — that  is,  the  products  of  his  imagination — to  be  real. 

Visual  hallucinations  may  be  indifferent,  threatening  or  bliss- 
ful in  nature.  Some  patients  portray  the  fantastic  pictures 
with  the  greatest  precision,  yet  are  unable  to  recognize  them  as 
deceptions.  They  see  themselves  hunted  and  exhausted,  sur- 
rounded by  dancing  skeletons,  who,  with  swinging  scythes,  push 
them  over  abysses;  or  they  witness  the  erection  of  a  scaffold,  by 
the  side  of  which  the  hangman,  surrounded  by  an  expectant  mul- 
titude, awaits  his  victims.  Others  depict  visions  of  rapture  ; 
they  see  themselves  in  heaven,  everything  resplendent  in  per- 
petual light;  they  are  received  and  welcomed  by  God  and  his 
angels,  all  of  whom  bow  low  at  their  coming.  In  some  patients 
the  visual  hallucinations  are  sensuously  less  marked,  represent- 
ing pictures  without  well-defined  form  or  plasticity;  others, 
again,  see  everything  as  it  is  in  nature.  It  must  not  be  forgotten 
that  the  contents  of  these  visions  are  entirely  dependent  upon  the 
patient's  conceptual  sphere.  An  anti-religious  person,  for  ex- 
ample, will  never  have  visual  hallucinations  that  show  him  the 
gates  of  heaven ;  nor  will  he  who  has  never  seen  a  snake  ever  see 
one  in  his  hallucinations. 


148     THE  UNSOUND  MIND  AND  THE  LAW 

Of  special  diagnostic  value  are  the  visual  hallucinations  of 
epileptics,  alcoholics,  cocainists  and  persons  suffering  from  the 
delirium  of  fever.  Epileptics  most  frequently  see  fire,  flames 
and  sparks,  but  they  also  have  visions  of  a  religious  fantastic 
nature.  The  physiognomic  expression  in  such  states  of  ecstasy  is 
a  dreamy,  blissful,  glorified  one.  Occasionally,  however,  they 
have  visions  of  an  alarming  character;  they  see  themselves  sur- 
rounded by  enemies  who  menace  them  with  drawn  knives;  or 
they  believe  themselves  to  be  followed  by  devils  and  threatening 
spooks  with  flaming  red  eyes.  Alarming  visions  of  this  sort  fre- 
quently provoke  the  epileptic  to  the  commission  of  the  most 
dangerous  acts  of  violence.  Another  phenomenon  encountered 
in  epileptics  is  that  they  not  infrequently  have  erroneous  sense 
deceptions  that  cause  them  to  see  all  objects  abnormally  large 
or  abnormally  small  (Makropsia  and  Mikropsia). 

In  alcoholics  the  visual  hallucinations  of  the  delirious  state 
outnumber  all  other  sense  deceptions  and  in  many  instances  con- 
stitute a  most  important  symptom  of  this  psychosis.  "Wherever 
such  visions  are  present  to  any  extent  the  suspicion  of  an  alco- 
holic psychosis  may  be  aroused.  No  less  characteristic  of  alco- 
holic delirium  than  the  visions  of  constantly  moving  masses  of 
spiders,  bugs,  mice  and  other  animals  is  the  occurrence  of  hal- 
lucinations in  other  sensory  fields,  which,  through  their  associ- 
ative conjunction,  cause  a  complete  misapprehension  of  the  pre- 
vailing situation,  so  that,  for  instance,  the  patient  believes  him- 
self to  be  at  home  following  his  usual  occupation.  As  a  result 
it  is  sometimes  possible,  from  the  manner  in  which  the  patient 
adapts  himself  to  the  imaginary  situation,  to  recognize  his  actual 
vocation  or  station  in  life.  Cocainists  also  suffer  from  visions  of 
animals,  just  like  those  of  alcoholics.  A  more  or  less  common 
characteristic  of  cocainism  is  a  marked  itching  of  the  skin,  and 
this  the  patient  delusionally  attributes  to  the  action  of  vermin. 
Upon  this  delusion  is  superimposed  in  turn  the  seeing  of  ani- 
mals. The  visual  hallucinations  that  occur  in  febrile  delirium 
are  usually  transitory,  coming  at  the  time  of  highest  tempera- 
ture, and  are  in  no  way  characteristic. 

Hallucinations  of  taste  and  smell  are  far  more  infrequent 
than  those  of  sight  and  hearing,  those  of  smell  being  somewhat 
more  frequent  than  those  of  taste.  In  the  majority  of  instances 
they  are  disagreeable  and  annoying  in  character.    As  a  rule  they 


THE  EXAMINATION  OF  THE  INSANE     149 

occur  only  in  combination  with  hallucinations  of  sight  or  hear- 
ing and  hence  are  of  but  little  diagnostic  value.  Nevertheless 
the  examining  physician  should  be  on  his  guard  when  patients 
maintain  that  their  food  has  a  peculiar  taste  or  that  the  air 
about  them  has  an  offensive  odor. 

Finally,  in  regard  to  hallucinations  of  general  sensibility,  we 
must  differentiate  between  general  tactile  hallucinations  and  de- 
ceptions implicating  the  sensibility  of  the  internal  organs  of  the 
body.  A  patient  who  has  hallucinations  of  general  sensation 
will  complain  of  his  skin  being  bitterly  cold  or  of  a  sensation  of 
itching,  tickling,  biting,  sticking,  prickling  or  crawling.  He  feels 
that  he  is  being  caught  up  and  shaken  to  and  fro;  that  electric 
currents  are  being  passed  suddenly  through  his  head;  or  again 
that  he  is  abruptly  embraced  and  petted,  or  that  his  skin  is  being 
traversed  by  painful  electric  or  magnetic  currents.  The  last 
mentioned  hallucination  is  typical  of  paranoia. 

In  this  connection  attention  should  be  called  to  the  fact  that 
sensations  produced  by  purely  psychic  means,  without  the  inter- 
vention of  specific  stimuli,  can  have  their  origin  only  in  the  con- 
ceptual sphere  of  the  patient.  The  patient  who  knows  nothing 
of  electricity  will  not  imagine  that  he  is  being  maltreated  with 
electric  currents.  A  century  ago,  when  few  people  knew  any- 
thing about  electricity,  there  were  undoubtedly  quite  as  many 
paranoiacs  as  there  are  to-day,  but  the  symptom  to  which  we 
have  just  referred  could  not  have  been  typical  of  paranoia  at 
that  time.  The  patient  had  other  hallucinations  of  general 
sensation. 

Deceptions  of  sensibility  of  the  internal  organs  of  the  body 
cause  a  patient  to  believe  that  snakes,  frogs  and  other  animals 
are  crawling  about  his  interior;  or  the  intestines  are  rotting  or 
protruding  from  the  abdomen ;  or  the  spinal  cord  is  destroyed  or 
is  thicker  upon  one  side  than  upon  the  other;  or  the  bones  are 
growing  through  the  flesh  or  wasting  away ;  or  the  blood  is  oozing 
from  the  fingers  and  toes,  one  leg  is  shorter  than  the  other,  the 
arms  have  turned  into  wood,  the  head  into  stone,  and  the  entire 
body  is  nothing  more  than  a  hollow  vessel  whose  contents  have 
ebbed  away. 

Special  mention  should  be  made  of  the  sense  deceptions  of  a 
sexual  nature.  Patients  having  hallucinations  of  this  kind  com- 
plain of  their  semen  being  drawn  or  driven  from  them.    Women 


150     THE  UNSOUND  MIND  AND  THE  LAW 

believe  they  have  been  violated  or  believe  themselves  to  be  preg- 
nant. How  notorious  are  the  calumnies  of  hysterical  women, 
who,  as  a  result  of  abnormal  body  sensations  of  a  sexual  kind, 
have  accused  physicians  of  assaulting  them  when  they  were 
under  the  influence  of  an  anajsthetic. 

The  value  of  hallucinations  of  body  sensation,  from  a  differen- 
tial diagnostic  point  of  view,  lies  in  the  fact  that  they  occur  in  a 
large  number  of  psychoses.  Prognostically  they  are  of  most  seri- 
ous import.  Most  frequently  they  occur  in  paranoid  processes  of 
disease,  in  the  terminal  states  of  melancholia  and  in  the  various 
forms  of  hypochondriasis.  In  general  it  may  be  said  that  all 
hallucinations  of  body  sensation  attributed  by  the  patient  to 
external  inimical  influences  are  paranoiac  in  character  and, 
therefore,  are  prognostically  decidedly  bad;  while  those  whose 
origin  cannot  be  attributed  to  persecutory  delusions  are  essen- 
tially of  a  hypochondriacal  character  and  must,  therefore,  be 
regarded  as  only  relatively  unfavorable.  The  diagnosis  will  also 
be  aided  by  the  knowledge  that  hallucinations  of  body  sensation 
usually  occur  in  conjunction  with  other  sense  deceptions.  Thus, 
in  paranoia,  they  are  almost  always  accompanied  by  hallucina- 
tions of  hearing,  smell  and  taste.  Hystero-hypochondriasis  is 
perhaps  the  only  form  of  psychosis  in  which  hallucinations  of 
body  sensation  are  encountered  as  isolated  occurrences.  Finally 
let  us  mention  the  fact  that  some  patients  feel  themselves  sud- 
denly lifted  and  thrown  into  the  air  at  a  time  when  they  are  in 
fact  lying  perfectly  quiet  in  bed.  Such  hallucinations  of  move- 
ment must  be  carefully  distinguished  from  similar  feelings  that 
occur  in  the  dreams  of  healthy  individuals. 

We  have  now  considered  sense  deceptions,  particularly  hallu- 
cinations, in  the  detail  justified  by  the  scope  of  the  present  work. 
Inasmuch  as  sense  deceptions  belong  to  the  symptoms  most  fre- 
quently encountered  in  mental  disease,  and  inasmuch  as  every 
hallucinating  person  must  be  considered  mentally  disordered 
even  if  such  disorder  be  only  transitory,  an  accurate  knowledge 
of  the  manner  in  which  sense  deceptions  arise  and  manifest  them- 
selves is  of  the  greatest  importance  for  every  one  who  may  be 
called  upon  to  pass  judgment  upon  dubious  mental  states.  It  is 
not  by  any  means  unusual  even  for  physicians  to  overlook  com- 
pletely the  existence  of  hallucinations,  particularly  when  pa- 
tients know  how  to  conceal  them  or  when  the  physician's  atten- 


THE  EXAMINATION  OF  THE  INSANE     151 

tiou  is  not  accidentally  directed  toward  them.  Such  disregard  is 
likely  to  result  in  diagnostic  errors  which  may  be  of  momentous 
import.  Not  only  is  the  presence  of  hallucinations  significant 
for  the  diagnosis  of  a  psychosis,  and,  therefore,  for  the  deter- 
mination of  a  patient's  freedom  of  will,  but  the  nature  and  the 
contents  of  the  hallucinations  will,  in  the  majority  of  instances, 
enable  us  also  to  draw  conclusions  regarding  the  precise  form 
the  psychosis  has  taken.  This  is  so  particularly  when  the  nature 
and  the  contents  of  the  sense  deceptions  are  considered  in  their 
relationship  to  other  psycho-pathological  symptoms.  We  should, 
therefore,  always  endeavor  to  determine  whether  sense  decep- 
tions exist,  what  senses  are  implicated  by  them  and  what  the 
contents  of  these  deceptions  may  be. 

For  purposes  of  differential  diagnosis,  we  have  still  to  consider 
the  erroneous  notions  that  stand  in  close  mutational  relation  to 
sense  deceptions. 

3.      DELUSIONS 

Almost  every  psychosis  has  certain  definite  characteristic  de- 
lusions. Consequently  the  value  of  such  delusions  for  differ- 
ential diagnosis  is  extraordinarily  great,  and  he  who  has  learned 
to  appreciate  the  specific  elements  in  a  delusion  will  never  be  in 
doubt  regarding  its  diagnostic  significance.  Here,  as  every- 
where, in  psychiatry,  one  must  not  rest  content  with  recognition  of 
the  fact  that  a  delusion  exists.  The  delusion  must  be  analyzed  as 
to  its  form  and  content,  and  as  to  the  relation  these  bear  to  other 
psycho-pathological  manifestations,  more  particularly  to  sense 
deceptions.  Speaking  in  a  general  way,  delusions  are  those 
notions  of  mentally  disordered  persons  that  are  contrary  to 
actual  fact,  yet,  not  being  open  to  correction,  lead  the  thought, 
judgment  and  conduct  of  the  patients  into  false  paths. 

Four  kinds  of  delusions  may  be  differentiated,  as  follows: 
1 — Paranoiac  delusions;  2 — Grandiose  delusions;  3 — Depressive 
or  melancholic  delusions;  4 — Hypochondriacal  delusions. 

Under  the  term  "paranoiac  delusions"  we  include  all  those 
erroneous  notions  whose  contents  are  in  any  way  derogatory  to 
the  person  affected  by  them.  The  chief  forms  are  notions  of  dis- 
paragement, of  imputation  and  of  persecution. 

The  mildest  form  is  represented  by  ideas  of  disparagement. 


152     THE  UNSOUND  MIND  AND  THE  LAW 

Individuals  thus  afflicted  consider  themselves  neglected  at  all 
times,  they  believe  every  one  else  receives  more  attention  than 
they  and  that  they  are  generally  badly  treated  and  misunder- 
stood. Such  notions  of  depreciation  are  encountered  most  often 
in  the  feebleminded  and  idiotic,  in  epileptics,  and  particularly 
in  that  large  class  of  hysterics  whose  egotism  is  so  marked  that 
they  become  envious  of  every  attention  shown  to  any  one  but 
themselves.  Notions  of  disparagement  are  diagnostic  of  paranoia 
only  when  it  can  be  shown  that  they  have  not  previously  been 
present. 

Of  decided  value  diagnostically  is  the  notion  of  imputation. 
Patients  having  ideas  of  this  type  attribute  conversations,  ges- 
tures, newspaper  notices,  etc.,  to  themselves.  Typical  of  this 
form  of  delusion  are  the  statements  so  often  made  by  patients 
that  all  conversations  held  in  their  presence  contain  references 
to  their  previous  life,  that  every  one  about  them  is  laughing  at 
them,  trying  to  anger  and  annoy  them,  or  endeavoring  to  insult 
and  deride  them.  In  every  occurrence,  even  the  most  insignifi- 
cant, these  patients  recognize  some  reference  to  themselves.  Any 
person  casually  sneezing,  coughing,  laughing  or  making  a  re- 
mark of  any  kind  in  their  presence  does  so  with  evil  intent ;  they 
believe  themselves  to  be  under  constant  surveillance,  and  the  con- 
duct of  the  people  about  them,  who  seem  to  them  to  be  giving 
surreptitious  signs  to  one  another,  leads  them  to  conclude  that 
they  are  the  object  of  some  evil  plan.  Soon  these  misconceptions 
give  way  to  visual  and  auditory  hallucinations.  Then  the  trans- 
formation of  the  notion  of  imputation  into  a  delusion  of  persecu- 
tion has  been  effected. 

Persecutory  delusions  are  encountered  in  many  psychoses. 
They  constitute  the  cardinal  symptom  of  paranoia.  This  diag- 
nosis, on  account  of  the  patient's  great  ability  to  dissimulate, 
may  in  certain  instances  be  one  of  considerable  difficulty.  Fre- 
quently the  most  dangerous  delusions  are  concealed  behind  a 
mask  of  complete  self-possession  and  orientation.  Then  usually 
the  ideas,  of  persecution  have  become  transformed  into  a  con- 
nected system  which,  because  of  its  logical  concentration,  indi- 
cates the  presence  of  decided  intellectual  force. 

In  the  paranoid  form  of  dementia  praecox,  however,  ideas  of 
persecution  often  very  early  bear  the  stamp  of  feebleminded- 
ness,    The  patient  believes  his  brain  is  being  pumped  out,  his 


THE  EXAMINATION  OF  THE  INSANE     153 

face  being  disfigured,  his  intestines  being  removed,  etc.  A 
special  character,  that  of  infringement  of  personal  rights,  is 
borne  by  the  persecutory  ideas  of  the  querulants  or  litigants 
who  are  constantly  carrying  on  law  suits,  who  believe  judges, 
lawyers  and  witnesses  have  been  bribed  or  are  banded  against 
them,  and  who  neither  by  argument  nor  experience  can  be  freed 
from  the  idea  that  they  cannot  obtain  justice.  Ideas  of  persecu- 
tion also  constitute  a  characteristic  symptom  of  acute  alcoholic 
insanity,  of  presenile  deterioration  and  of  senile  dementia  itself. 
Yet,  in  these  instances,  the  persecutory  ideas  never  become  sys- 
tematized, and  they  are  either  persistently  monotonous  or  con- 
stantly changing. 

In  dementia  paralytica  (general  paresis),  ideas  of  persecution 
may  frequently  be  observed.  Like  all  ideas  of  paretics,  their 
paranoid  delusions  also  bear  an  impress  that  is  feebleminded, 
absurd,  illogical  and  impossible.  Thus  a  paretic  with  delusions 
of  persecution  may  believe  his  food  to  be  poisoned  and  refuse  to 
eat  even  when  other  persons  eat  from  the  same  dish.  Very  early 
in  the  course  of  general  paresis,  when  manifest  somatic  symp- 
toms are  sometimes  still  missing  and  laboratory  tests  fail  to  clear 
up  the  diagnosis,  it  is  usually  the  paretic's  lack  of  energy  and 
self-control,  his  constant  emotional  changeability  and  especially 
the  sense  of  elation  (euphoria)  so  characteristic  of  his  condition, 
that  will  enable  us  to  decide  we  are  dealing  with  a  dementia 
paralytica  and  not  with  a  paranoia. 

In  epileptic  states,  too,  paranoid  delusions  of  persecution  are 
of  rather  frequent  occurrence.  They  set  in  suddenly  in  the  form 
of  acute  delusions  in  which  the  patients  have  innumerable 
visions  of  the  most  lurid  kind,  believe  themselves  to  be  sur- 
rounded by  enemies  and  are  in  a  state  of  the  utmost  excitement. 
Usually  such  acute  persecutory  delusions  occur  just  before  or 
directly  after  an  epileptic  convulsion.  They  are  always  tran- 
sient, but  while  they  are  present  the  patients  are  most  danger- 
ous, frequently  committing  fearful  deeds  of  violence  under  the 
spell.  Not  infrequently,  after  the  excitement  has  abated,  a  state 
of  stupor  or,  less  often,  one  of  ecstasy  sets  in.  The  presence  of 
other  concomitant  epileptic  symptoms  will  confirm  the  diagnosis. 
Single  persecutory  ideas  may  be  permanently  present  in  some 
epileptics.  Also  in  the  periodic  and  circular  psychoses,  trans- 
itory persecutory  ideas  may  be  encountered,  but  only  after  the 


154     THE  UNSOUND  MIND  AND  THE  LAW 

disease  has  made  considerable  advance.  In  the  intervallary  free 
periods  and  often  during  the  attacks  themselves,  the  patients 
very  well  know  they  have  been  troubled  by  delusions.  In  hys- 
terics, too,  ideas  of  persecution  are  sometimes  transitorily  pres- 
ent, but  are  to  be  looked  upon  as  a  result  of  suggestions  im- 
planted by  other  persons.  Fortunately  the  delusions  which  hys- 
terics acquire  in  consequence  of  their  suggestibility  are  not 
tenacious ;  they  exert  but  little  influence  upon  the  patient 's  con- 
duct and,  as  a  rule,  soon  disappear  if  their  existence  be  skil- 
fully ignored.  Very  different  are  those  infrequently  occurring 
twilight  states  of  hysteria  that  are  accompanied  by  appalling  sense 
deceptions  with  actual  delusions  of  persecution  (usually  of  an 
erotic  nature). 

While,  in  the  instances  we  have  thus  far  noted,  the  patients 
endeavor  to  protect  themselves  against  their  supposed  enemies, 
sufferers  from  melancholia  maintain  a  perfectly  passive  attitude 
toward  their  persecutory  delusions.  Despondently  they  talk  of 
the  persecutions  to  which  they  are  subject,  but  they  bear  them 
with  equanimity  as  a  well-deserved  punishment  for  sins  that 
they  accuse  themselves  of  having  committed.  A  systematization 
of  delusions  never  occurs  in  melancholia.  The  earlier  these  de- 
lusions arise  the  more  persistent  they  are,  and  the  more  posi- 
tively they  are  maintained  the  more  unfavorable  will  be  the 
prognosis. 

Not  quite  so  frequent  in  occurrence  as  the  paranoid  delusions 
are  those  of  an  expansive  or  grandiose  character.  In  many  in- 
stances delusions  of  grandeur  and  delusions  of  disparagement 
are  associated  in  one  and  the  same  psychosis,  so  that  the  two 
kinds  will  alternate  in  occupying  the  foreground  of  the  picture. 
In  the  later  stages  of  paranoia,  delusions  of  grandeur  are  of  fre- 
quent occurrence.  Those  encountered  in  the  paranoid  form  of 
dementia  praecox  differ  materially  from  those  met  with  in  classic 
paranoia.  They  occur  earlier  in  the  course  of  the  disease,  often 
during  the  first  days  or  weeks,  sometimes  being  the  result  of 
hallucinations;  besides  they  are  extraordinarily  changeable  and 
replete  with  ornate  adventuresome  grandiose  ideas  of  the  most 
ridiculous  nature.  Frequently  also — just  as  in  paresis — sug- 
gestive questioning  will  suffice  to  call  forth  new  and  changing 
fantastic  delusions  of  grandeur.  Factors  of  decisive  value  in 
the  differential  diagnosis  of  dementia  prtecox  are  the  youthful- 


THE  EXAMINATION  OF  THE  INSANE     155 

ness  of  the  patient,  the  evident  weakmindedness,  the  monotonous 
unemotional  manner  with  which  the  grandiose  beliefs  are  un- 
folded and  their  very  slight  influence  upon  the  patient 's  bearing 
and  conduct. 

The  delusions  of  grandeur  present  in  litigious  or  querulant 
paranoiacs  are  as  a  rule  not  so  vivid  as  in  the  other  forms  of  this 
disease.  Almost  always,  however,  there  is  present  an  extraor- 
dinary augmentation  of  conceit,  an  exaggerated  belief  in  their 
own  importance,  that  clearly  manifests  itself  in  the  speech  and 
writings  of  these  judicial  disputants.  Almost  all  querulants  at- 
tach undue  significance  to  the  law  suits  that  they  institute  and 
believe  the  court's  most  important  duty  rests  in  attention  to 
their  personal  affairs.  In  most  of  their  suits  for  imaginary  dam- 
ages, fabulous  sums  are  demanded  in  compensation.  In  acute 
alcoholic  insanity  delusions  of  persecution  and  transitory  fan- 
tastic delusions  of  grandeur  may  arise  side  by  side.  The  acute 
stage  having  run  its  course,  the  delusions  which  are  dependent 
for  their  existence  upon  delirium  and  hallucinations  no  longer 
appear;  on  the  other  hand  the  delusions  that  accompany  the 
chronic  alcoholic  psychoses,  such  as  notions  of  poisoning  and  of 
marital  infidelity,  are  generally  of  a  more  enduring  character, 
and  disappear  only  with  a  cure  of  the  alcoholism  itself. 

In  senile  dementia  feebleminded  ideas  of  grandeur  occasion- 
ally arise,  which,  in  connection  with  other  symptoms  of  de- 
mentia and  of  senility  (weakness  of  memory,  intellectual  defect, 
etc.),  make  the  diagnosis  easy.  In  exceptional  cases — for  in- 
stance, where  pupilary  rigidity  exists — the  differential  diagnosis 
from  a  brain  syphilis  in  its  late  stages  and  from  paresis  may 
be  difficult,  and  where  the  complement  fixation  test  gives  no  posi- 
tive information,  may  be  entirely  impossible.  In  the  classic  form 
of  paresis,  ideas  of  grandeur  constitute  a  symptom  that  is  di- 
rectly characteristic.  Whenever  delusions  of  grandeur  are  pres- 
ent in  any  psychosis  that  occurs  in  individuals  of  middle  age, 
paresis  should  be  suspected.  The  grandiose  ideas  of  paretics  are 
profuse,  they  change  constantly,  contradict  one  another  and  give 
evidence  of  a  more  or  less  marked  degree  of  enfeebled  judgment. 
On  one  and  the  same  day  a  paretic  may  be  the  ruler  of  the 
world,  a  multi-millionaire,  the  Pope  or  God.  He  possesses  gigan- 
tic powers,  can  lift  a  weight  of  one  thousand  tons  in  one  hand, 
has  accomplished  the  most  heroic   deeds,   accumulated  untold 


156     THE  UNSOUND  MIND  AND  THE  LAW 

riches,  given  life  to  thousands  of  miraculous  offspring,  etc.  By 
means  of  suggestive  questioning,  numerous  new  ideas  of  gran- 
deur of  the  most  ridiculous  kind  may  in  most  instances  be  aroused. 
The  diagnosis  of  a  classic  case  of  paresis  can  cause  no  difficulty. 
The  weakness  of  judgment,  the  defective  intelligence,  the  char- 
acter of  the  delusions  and  the  physical  symptoms  will  all  be  de- 
terminative. In  exceptional  cases  of  delirium  tremens,  however, 
delusions  of  grandeur  may  be  so  profuse  that  the  case  will  seem 
to  be  one  of  paresis,  and  so  long  as  the  delusions  exist,  the  diag- 
nosis may  remain  uncertain.  If  the  grandiose  ideas  persist 
after  the  delirium  has  run  its  course,  the  diagnosis  of  paresis 
will  no  longer  be  in  doubt.  On  the  other  hand,  when  the  de- 
lirium and  the  grandiose  ideas  disappear  simultaneously  and  no 
marked  physical  symptoms  of  paresis  (pupilary  rigidity,  speech 
defect,  etc.)  exist,  we  may  be  sure  we  are  dealing  with  an  un- 
usual case  of  alcoholic  insanity. 

The  grandiose  notions  of  acute  mania  or  of  the  manic  stage  of 
a  manic  depressive  psychosis  usually  remain  within  the  bounds 
of  possibility,  being  distinguished  by  their  boastfulness  and  over- 
bearing character  as  well  as  by  their  great  fugaciousness.  But 
occasionally  we  encounter  grandiose  ideas  of  the  most  absurd 
kind,  directly  remindful  of  those  so  characteristic  of  paresis.  An 
energetic  appeal  will  often  cause  the  maniacal  patient  to  cor- 
rect his  ideas  of  grandeur,  and  this  alone  will  demonstrate  that 
paresis  does  not  exist.  In  other  cases  the  absence  of  all  paretic 
symptoms,  as  well  as  the  absence  of  the  signs  of  true  mania 
(exaltation,  flight  of  ideas,  etc.),  will  determine  the  diagnosis. 

The  expansive  ideas  that  occur  in  melancholia  occupy  a  most 
peculiar  position.  Melancholia  in  itself  furnishes  a  thoroughly 
arid  soil  for  the  development  of  grandiose  delusions.  When 
they  do  occur,  they  merely  serve  to  place  the  sinfulness  of  the 
patient  in  a  more  intense  light,  and  thus  represent  a  contrast 
which  constitutes  a  basis  for  melancholic  delusions.  A  melan- 
choliac  may  believe  that  he  will  live  forever,  that  he  cannot  die, 
but  he  will  also  believe  that  his  imperishability  will  continue 
only  in  order  that  he  may  suffer  unending  torture  as  a  punish- 
ment for  his  own  failings  or  wickedness.  Such  patients  believe 
themselves  to  be  the  cause  of  all  the  evil  that  exists  in  the  world ; 
all  their  talents  and  all  their  good  qualities  serve  only  for  the 
accomplishment  of  evil.    Very  exceptionally,  in  the  later  stages 


THE  EXAMINATION  OF  THE  INSANE      157 

of  melancholia,  we  encounter  actual  delusions  of  grandeur, 
which  fantastically  exalt  the  patients  above  those  surrounding 
them. 

We  have  now  reached  the  third  category  of  delusions,  the 
depressive  or  melancholic  ones.  These  constitute  an  antithesis 
to  the  delusions  of  expansive  nature  and  occur  not  only  in 
actual  melancholia,  but  in  all  states  of  depression.  As  delu- 
sions of  sinfulness  they  represent  a  symptom  that  is  constant 
in  true  melancholia.  The  patients  review  their  entire  lives  and 
in  every  past  occurrence  they  discover  faults  which  they  at- 
tribute to  weakness  of  character  or  wilful  misdeeds.  The  most 
insignificant  oversight  or  neglect  which  they  recall  is  magnified 
into  a  heinous  crime.  Anything  they  have  ever  done  or  omitted 
to  do  becomes  a  source  of  self-reproach  and  self-accusation. 
They  believe  they  have  brought  misfortune  upon  themselves 
and  their  families,  or  that  they  have  thrown  other  people  into 
want  and  misery.  They  regard  themselves  as  unworthy  and 
vile,  the  greatest  sinners  that  have  ever  existed.  While  most 
people  tend  to  minimize  and  condone  their  own  faults,  the  true 
melancholiac  is  dominated  by  a  peculiar  compulsion  that  causes 
him  to  exaggerate  his  faults  beyond  measure  and  even  to  dis- 
cover failings  where  none  exist.  Frequently  the  delusion  of  sin- 
fulness is  associated  with  one  of  impoverishment.  The  patients 
complain  that  they  and  their  families  are  completely  in  want, 
have  no  roof  over  their  heads,  that  their  children  must  starve, 
beg  for  food,  etc.  Less  frequently  the  patients  are  dominated 
by  nihilistic  delusions.  Such  melancholiacs  believe  the  entire 
world  has  been  submerged,  everything  has  been  destroyed,  every 
one  has  been  killed,  everything  about  them  is  merely  a  shadow 
or  shell;  they  themselves  are  the  only  living  beings  upon  earth 
and  they  have  been  rendered  immortal  in  order  that  they  may 
do  unending  penance  for  the  sins  they  have  committed.  Occa- 
sionally the  depressive  notions  manifest  themselves  under  the 
guise  of  a  delusion  of  transformation ;  then  the  patients  believe 
themselves  transformed  into  wolves,  dogs  or  other  animals ;  they 
hop,  crawl  and  jump  about  upon  all  fours,  bark,  bite  and  in 
every  way  try  to  imitate  the  particular  animal.  In  still  other 
instances  the  notion  of  transformation  embraces  not  themselves, 
but  their  surroundings.  The  entire  extraneous  world  seems 
transformed  in  an  appalling  and  horrible  manner.    The  people 


158     THE  UNSOUND  MIND  AND  THE  LAW 

about  them  are  but  contrivances  or  masks  that  move  about  arti- 
ficially. The  entire  world  is  a  morgue,  trees  and  hills,  sun  and 
moon,  wind  and  weather,  all  have  been  given  terrifying  aspects 
in  order  to  frighten  the  patient. 

Although  expansive  ideas  of  grandeur  accord  more  fully  with 
paresis,  and  depressive  ideas  of  depreciation  more  thoroughly 
with  melancholia,  it  is  not  unusual  for  melancholic  delusions  to 
occur  in  the  commencement  of  a  paresis,  just  as  in  the  later 
stages  of  melancholia  we  may  encounter  actual  ideas  of 
grandeur.  The  depressive  delusions  of  paretics,  like  all  other 
delusions,  are  markedly  feebleminded  and  uncritical.  This  be- 
comes evident  when  we  note  the  ease  with  which  ideas  that  are 
emphatically  contradictory  to  their  delusions  may  be  implanted 
in  such  patients  by  means  of  suggestion,  while  only  exception- 
ally can  the  systematized  delusions  of  paranoiacs  be  so  in- 
fluenced. In  the  commencement  of  a  paresis  delusions  of  un- 
worthiness  and  of  sinfulness  arise  just  as  they  do  in  melan- 
cholia. This  fact  makes  a  differential  diagnosis  of  special  im- 
portance, and  in  certain  cases  considerable  difficulty  may  be  en- 
countered. Occasionally  no  definite  diagnosis  is  possible  until 
the  numerous  irritative  symptoms  that  usually  accompany  the 
early  stages  of  paresis  have  become  more  pronounced.  As  the 
disease  progresses,  the  depressive  delusions  recede  or  combine 
with  other  delusions.  The  delusion  of  sinfulness,  moreover,  is  a 
very  frequent  symptom  in  the  depressive  phases  of  manic  de- 
pressive psychoses,  of  hysteria  and  of  epilepsy.  In  hysterics, 
the  depressive  ideas  are  mostly  vague,  monotonous  and  sparse, 
or  the  self-accusations  are  markedly  exaggerated,  romantic,  and 
what  is  especially  significant  of  hysteria,  calculated  to  make  the 
patient  interesting.  In  epileptics  the  ideas  of  sinfulness  are 
mostly  of  a  religious  nature. 

The  depressive  ideas  arising  in  the  first  stages  of  paranoia  are 
frequently  confounded  with  those  of  melancholia,  but  when  they 
are  more  carefully  analyzed  certain  essential  differences  will  be 
disclosed.  The  melancholiae  mentally  reviews  his  entire  life  in 
order  to  elicit  more  and  still  more  evidences  of  his  fault  or  guilt. 
The  paranoiac,  on  the  other  hand,  dissects  and  analyzes  his  past 
life  for  the  purpose  merely  of  justifying  himself — in  order  to 
show  he  is  innocent  and  a  victim  of  inimical  persons.  Depres- 
sive delusions  bearing  the  guise  of  typical  delusions  of  sinful- 


THE  EXAMINATION  OF  THE  INSANE     159 

ness  are  frequently  encountered  in  the  beginning  of  all  forms 
of  dementia  praecox.  As  a  result  the  diagnosis  of  melancholia 
is  generally  made,  although  in  this  case  an  early  and  correct 
diagnosis  would  be  of  particular  importance.  Therefore,  when 
confronted  by  a  youthful  individual  having  sorrowful  moods, 
ideas  of  sinfulness  and  other  depressive  delusions,  one  must  al- 
ways bear  in  mind  the  possibility  of  the  development  of  some 
process  of  mental  enfeeblement  (dementia  praecox),  and  should 
only  assume  the  existence  of  a  simple  melancholia  when  the 
latter  diagnosis  is  in  accord  with  other  existing  symptoms  and 
when,  more  particularly,  no  defect  of  memory  or  of  intelligence 
exists. 

A  depressive  state  with  self-accusatory  ideas  is  also  encoun- 
tered in  the  majority  of  cases  of  senile  dementia.  Here,  however, 
these  notions  are  usually  so  completely  interwoven  with  other 
delusions  and  so  clearly  combined  with  other  symptoms  of  be- 
ginning senile  deterioration  that  the  diagnosis  cannot  long  re- 
main in  doubt.  Sometimes  the  differential  diagnosis  between  a 
senile  dementia  and  a  melancholia  can  be  determined  only  after 
the  lapse  of  considerable  time. 

Finally,  as  regards  hypochondriacal  delusions,  I  would  par- 
ticularly emphasize  the  fact  there  exists  no  "hypochondria"  of 
the  sort  so  commonly  spoken  of  by  the  laity.  The  majority  of 
hypochondriacs  must  be  considered  as  belonging  to  a  class  af- 
fected by  what  is  best  designated  as  hystero-hypochondriasis. 
This  occurs  most  frequently  around  or  after  middle  age — in 
women  at  the  time  of  the  menopause — when  in  other  persons 
of  a  different  temperament  a  melancholia  would  develop.  Such 
patients  concern  themselves  solely  about  their  own  bodies  and 
their  imaginary  diseases.  They  are  always  in  a  state  of  ap- 
prehension, now  fearing  cancer,  now  locomotor  ataxia  and  now 
paresis.  Frequently  certain  objective  signs  of  the  most  insig- 
nificant nature  are  the  cause  of  fresh  hypochondriacal  fears,  and 
these  are  likely  to  receive  new  support  through  the  reading  of 
popular  medical  writings.  The  prognosis  of  this  hystero- 
hypochondriasis  remains  good  until  hypochondriacal  delusions 
and  abnormal  sensations  are  permanently  present.  The  more 
pronounced  the  hysterical  traits  of  the  disease,  the  better  the 
prognosis.  The  hypochondriacal  delusions  of  paranoia  differ 
from  those  of  hystero-hypochondriasis  by  the  absence  of  any 


160     THE  UNSOUND  MIND  AND  THE  LAW 

discoverable  objective  cause.  Moreover  the  paranoiac  attributes 
all  his  hypochondriacal  complaints  to  the  activities  of  his 
enemies ;  he  charges  they  are  tearing  out  his  spinal  cord,  laying 
bare  his  brain,  depriving  him  of  his  semen,  paralyzing  his  limbs, 
taking  out  his  intestines  and  replacing  them  by  rubber  tubes, 
etc.  The  hypochondriac,  on  the  other  hand,  attributes  his 
troubles  to  diseases  which  he  thinks  he  actually  has.  The  things 
the  paranoiac  believes  are  impossibilities.  What  the  hypochon- 
driac believes  is  perfectly  possible,  only  he  is  wrong  in  believ- 
ing it. 

Hypochondriacal  delusions  are  very  frequent  in  melancholia. 
In  the  cases  having  a  favorable  prognosis,  they  are  of  but  fleet- 
ing duration  and  remain  within  moderate  bounds ;  the  stomach 
is  closed  up,  nothing  can  be  digested,  the  bowels  no  longer  move, 
the  nervous  system  is  exhausted,  etc.  The  more  nonsensical  the 
hypochondriacal  delusions  of  the  melancholiac  become  and  the 
more  intense  they  are,  the  more  unfavorable  will  be  the 
prognosis. 

The  statement  already  made  of  the  other  delusions  of  paretics 
applies  also  to  their  frequently  hypochondriacal  complaints. 
These  are  childish,  senseless  and  often  immeasurably  fantastic. 
They  are  very  changeable  and  usually  combine  with  other 
paretic  delusions  of  a  paranoid  or  expansive  nature.  A  patient 
thus  afflicted  will  maintain  that  everything  within  him  has  rotted 
away,  that  he  no  longer  has  a  mouth,  heart,  or  intestines,  that 
his  head  is  of  stone,  his  bowels  filled  with  gold,  his  brain  but  a 
grain  of  dust,  etc.  Not  infrequently  the  delusions  are  micro- 
manic, so  the  patient  believes  his  body  has  shrunk,  so  he  looks 
like  a  dwarf  or  a  little  child,  that  his  legs  are  so  small  they  can- 
not support  the  body,  or  even  that  the  body  has  become  so  light 
that  it  will  be  blown  away  by  the  first  gust  of  wind. 

Hypochondriacal  delusions,  generally  bearing  a  feebleminded 
impress,  are  of  frequent  occurrence  in  senile  dementia.  Those 
occurring  in  dementia  prascox  are  usually  absurd  in  the  high- 
est degree.  The  patient  may  believe  his  nose  to  be  obstructed  by 
a  diamond,  his  lungs  to  be  shriveled  up,  his  blood  congealed, 
his  brain  liquefied,  etc. 

In  chronic  alcoholism,  hypochondriacal  delusions  of  the  most 
varied  kind  occur  as  a  result  of  the  abnormal  sensation  pro- 
duced by  the  different  organic  lesions  to  which  drinkers  are  sub- 


THE  EXAMINATION  OF  THE  INSANE     161 

ject  (chronic  catarrh  of  the  stomach  and  intestines,  diseases  of 
the  liver,  etc.).  These  delusions  may  become  permanently  estab- 
lished. On  the  other  hand,  the  hypochondriacal  ideas  of  epilep- 
tics are  usually  variable  and  fugaceous;  not  infrequently  they 
constitute  the  first  signs  of  a  beginning  twilight  or  excited  state. 

4.      THE   MEMORY 

Memory,  intelligence  and  judgment  must  still  be  examined 
and  the  results  utilized  for  diagnostic  purposes.  Disorders  of 
memory  are  of  frequent  occurrence  in  many  psychoses,  and 
often  they  constitute  symptoms  of  differential  diagnostic  value. 
From  the  viewpoint  of  practical  diagnosis  we  must  differentiate 
two  qualities  of  memory :  the  power  of  storing  a  large  stock  of 
concepts  in  the  brain  and  the  power  of  constantly  adding  new 
ideas  to  the  old  memory  store.  The  memory  store,  which  often 
reaches  back  into  earliest  childhood,  furnishes  a  firmly  fixed 
supply  of  memory  material.  This  memory  for  the  distant  past 
paleomnemnesis)  is  coupled  with  the  memory  for  the  recent  past 
(neomnemnesis).  By  the  latter  is  meant  the  power  of  con- 
stantly adding  new  ideas  to  the  old  memory  store.  These  two 
memory  components  may  be  differently  developed  even  in  a 
normal  individual.  The  memory  for  recent  events  may  be  good, 
while  that  for  far  distant  impressions  is  bad ;  or  there  may  be  a 
marked  degree  of  forgetfulness  for  the  happenings  of  the  recent 
past,  while  memory  for  the  occurrences  of  childhood  shows  no 
gaps.  The  latter  condition  usually  obtains  as  a  physiological 
manifestation  in  old  age.  Under  pathological  conditions,  de- 
fects of  memory  of  course  are  of  a  more  pronounced  kind.  From 
the  point  of  view  of  differential  diagnosis,  the  fact  should  not  be 
overlooked  that  in  some  psychoses  memory  becomes  affected 
equally  in  both  directions,  while  in  others  there  exists  an  en- 
feebled memory  or  loss  of  recollection  only  for  certain  portions 
of  the  past.  In  the  insane,  therefore,  the  two  qualities  of  mem- 
ory must  be  tested  separately  and  it  must  be  borne  in  mind  that 
both  qualities  may  be  restricted  to  the  same  degree,  or  else  one 
quality  alone  may  have  suffered  a  loss,  while  the  other  has  re- 
mained intact. 

Memory  for  the  more  distant  past  is  tested  best  by  first  ob- 
taining an  anamnesis  from  the  patient  himself  and  by  requiring 


162     THE  UNSOUND  MIND  AND  THE  LAW 

him  to  make  precise  statements  of  the  time  at  which  the  various 
occurrences  took  place.  If  this  he  done,  marked  disturbance  of 
memory  will  often  be  elicited.  Uncertainty  in  statements,  errors 
and  contradictions  will  easily  attract  our  notice.  The  anamnes- 
tic questions  should  cover  the  patient's  entire  previous  life;  he 
should  be  asked  when  and  where  he  was  born,  when,  where  and 
how  long  he  attended  school,  what  trade  he  learned,  whether  he 
is  married,  whether  he  has  children  and  how  old  they  are,  what 
important  occurrences  have  taken  place  during  his  life,  etc.  The 
test  should  be  extended  to  determine  how  much  of  the  knowl- 
edge acquired  in  school  has  become  permanently  fixed  in  the 
memory.  In  this  connection,  of  course,  careful  consideration 
must  be  given  the  patient's  cultural  development.  If  his  educa- 
tional opportunity  has  been  solely  that  of  a  primary  school,  he 
should  be  asked  only  the  most  elementary  questions  in  history, 
geography,  arithmetic,  etc.  The  college  graduate,  however,  must 
be  subjected  to  a  test  in  higher  mathematics,  classics  and  the 
natural  sciences.  It  need  hardly  be  stated  that  the  patient 
should  not  be  permitted  to  feel  he  is  being  examined.  The  test 
should  be  conducted  in  the  form  of  an  ordinary  conversation, 
in  the  course  of  which  the  physician  will  always  hit  upon  certain 
topics  that  prove  to  be  of  special  interest  to  the  patient  and 
these  will  furnish  a  point  of  departure  for  further  questions. 
Defects  of  memory  are  very  important  for  the  diagnosis  of 
paresis  and  senile  dementia.  Every  psychosis  of  middle  life 
that  reveals  the  existence  of  disorders  of  memory  will  primarily 
arouse  suspicion  of  an  existing  paresis.  As  memory  disturb- 
ances of  mild  degree  constitute  an  early  symptom  of  this  dis- 
ease, careful  and  frequent  memory  tests  are  imperative  in  all 
suspected  cases.  The  memory  disturbances  in  the  beginning 
of  the  disease  are  only  isolated  ones.  Here  and  there  an  image 
has  disappeared  and  has  left  a  break  in  the  broad  perceptual 
circle.  Gradually  these  breaks  become  more  and  more  extended 
until  the  entire  memory  field  is  affected.  When  such  patients 
are  asked  to  recount  incidents  of  their  past  life,  their  statements 
will  be  incoherent  and  contradictory.  The  recollection  of  im- 
portant occurrences  is  uncertain;  they  describe  certain  happen- 
ings first  in  one  way  and  then  in  another.  They  are  unable  to 
recollect  the  simplest  dates,  they  forget  their  own  birth  years, 
the  birthdays  of  their  nearest  relatives  and  even  happenings  of 


THE  EXAMINATION  OF  THE  INSANE     163 

greatest  significance  in  their  own  careers.  In  consequence  of 
numerous  and  progressive  memory  defects,  they  also  lose  their 
orientation  for  the  past  and  are  no  longer  able  to  arrange  the 
happenings  of  their  lives  in  an  orderly  sequence — in  other 
words,  the  chronologic  orientation  regarding  their  own  lives  is 
lost.  A  patient  of  this  type  is  likely  to  maintain  that  things 
which  occurred  a  decade  ago  have  taken  place  within  the  last 
few  minutes,  or  that  he  has  been  in  the  asylum  only  a  week, 
although  actually  there  for  years. 

A  test  of  the  paretic 's  school  knowledge  very  often  will  reveal 
numerous  defects  early  in  the  course  of  the  disease.  He  will 
forget  the  simplest  facts  in  history  and  geography.  Some 
paretics  retain  a  certain  ability  for  calculation  and  for  arith- 
metical problems  for  a  considerable  time,  but  sooner  or  later 
defects  will  crop  out.  Each  patient  should  repeatedly  be  asked 
to  solve  entire  series  of  arithmetical  problems  of  the  most  varied 
kind  until  a  conclusive  diagnosis  has  been  reached.  Tests  in 
subtraction  will  be  found  most  suitable  for  disclosing  any  loss 
of  arithmetical  ability,  because  experience  has  shown  such  prob- 
lems cause  these  patients  most  difficulty. 

At  all  events  a  comprehensive  memory  test  must  be  carried 
out  in  all  mental  disorders.  Many  persons  have  a  particularly 
good  memory  for  numbers,  tones,  names,  etc.  These  special  por- 
tions of  the  memory  store  seem  able  to  withstand  the  paretic 
ravages  much  longer  than  the  rest  of  the  memory  contents  and, 
therefore,  a  superficial  test  would  fail  to  reveal  the  existence  of 
any  material  defect.  Consequently  the  memory  should  be  put 
to  an  examination  as  broad  and  thorough  as  possible.  When- 
ever a  middle-aged  person  having  disorders  of  memory  also 
manifests  psychic  disturbances,  such  as  depression,  moodiness, 
nervousness,  irritability  and  sleeplessness,  the  possibility  of  a 
paresis  should  be  seriously  entertained.  If  these  symptoms  are 
accompanied  by  tremor,  speech  disturbances,  inequality  in  the 
size  of  the  pupils  or  even  tabic  symptoms,  the  diagnosis  of 
paresis  may  be  considered  certain.  In  order,  however,  to  arrive 
at  an  early  diagnosis  of  paresis  it  is  essential  primarily  to 
recognize  the  slight  memory  defects  that  mark  the  very  begin- 
ning of  this  disease. 

In  senile  dementia,  defects  of  memory  for  distant  happen- 
ings are  encountered  later  in  the  course  of  the  disease.     Hence, 


164     THE  UNSOUND  MIND  AND  THE  LAW 

an  anamnesis  given  by  the  patient  at  the  beginning  of  the 
psychosis  often  will  show  a  complete  power  of  recollection  for 
things  long  past,  while  a  test  of  the  knowledge  acquired  later 
in  school,  including  that  of  arithmetic,  will  usually  reveal 
memory  defects. 

Testing  the  memory  for  recent  events  is  usually  accomplished 
by  interrogating  the  patient  minutely  concerning  the  occur- 
rences and  experiences  of  the  last  few  hours,  days  or  weeks. 
The  results  obtained  may  be  checked  up  experimentally  by  ask- 
ing the  patient  to  remember  a  given  sentence,  number  or  unusual 
word,  and  then  after  a  lapse  of  time  ascertaining  whether  he 
has  been  able  to  retain  it  in  mind  or  not.  Or  the  patient  may 
be  shown  a  picture  with  instructions  to  observe  it  carefully  and 
to  describe  it;  soon  afterward  he  is  asked  to  tell  what  details  of 
the  picture  he  still  remembers.  Thus  we  will  be  able  to  judge 
whether  and  to  what  extent  disorders  of  memory  for  recent 
events  are  present. 

Such  disorders  are  characteristic  of  senile  dementia.  As  we 
have  already  stated,  in  old  people  suffering  from  dementia  the 
power  of  recollection  for  events  long  past  usually  remains  un- 
affected for  a  considerable  period  of  time.  We  well  know  how 
vividly  and  strikingly  the  aged  can  recount  happenings  of  their 
early  lives,  but  this  faculty  is  usually  counterbalanced  by  a 
manifest  disturbance  in  their  power  of  cognition,  in  their  ability 
to  receive  new  impressions.  Patients  with  memory  defects  for 
recent  events  permanently  lose  their  orientation  for  time,  They 
can  no  longer  tell  correctly  the  day  of  the  week,  the  date,  nor 
the  year;  they  forget  things  a  few  minutes  after  they  are  said 
or  done;  they  recount  the  same  stories  over  and  over  again 
without  knowing  they  are  repeating  them;  they  fail  to  recog- 
nize persons  immediately  after  being  introduced  to  them.  A 
carefully  instituted  experimental  test  will  reveal  the  existing 
deficiency  still  more  clearly.  As  it  progresses  senile  dementia 
is  always  accompanied  by  a  gradual  destruction  of  memory  for 
the  distant  past  as  well.  Loss  of  memory  for  recent  events  as 
well  as  for  those  long  past  is  one  of  the  concomitants  of  the 
retrogressive  process  to  which  all  persons  are  subject  with  ad- 
vancing age.  In  a  given  instance,  in  fact,  it  may  be  questionable 
whether  the  loss  of  memory  is  normal  or  pathological.  But  in 
young  persons  or  persons  of  middle  age  it  is  distinctly  patho- 


THE  EXAMINATION  OF  THE  INSANE     165 

logical  to  show  defects  of  memory  for  recent  events.  Instances 
of  this  sort  are  found  in  pre-senile  dementia,  and  still  more  so 
in  dementia  prEecox.  In  a  well-developed  picture  of  dementia 
praBcox  we  always  note  disorder  of  memory  for  recent  events 
because  the  patient,  becoming  dull  and  indifferent,  no  longer 
receives  new  impressions.  For  the  diagnosis  of  this  disease, 
however,  the  disorders  of  memory  are  of  only  secondary  im- 
portance, because  they  occur  after  dementia  has  set  in,  and  by 
that  time  the  diagnosis  should  have  been  made  from  other 
symptoms. 

But  this  same  disorder  of  memory  for  recent  events  is  a  dis- 
tinguishing symptom  of  polyneuritic  (Korsakoff's)  psychosis,  a 
symptom  so  prominent  that  it  cannot  possibly  be  overlooked. 
The  patients  immediately  forget  all  they  hear  or  see  and  they 
have  no  cognizance  of  time  or  place  even  when  the  facts  have 
been  plainly  put  before  them.  They  see  and  hear,  their  senses 
are  receptive  to  all  impressions,  but  no  new  experience  is  gained, 
no  new  concept  acquired.  Awake,  they  dream  and  pass  their 
lives  as  in  a  trance.  To  the  examiner  conversant  with  the  pic- 
ture of  this  disease  the  accentuated  cases  can  present  no  diag- 
nostic difficulties.  From  the  anamnesis  as  well  as  from  the  ob- 
jective symptoms  of  alcoholic  polyneuritis,  it  will  at  once  become 
apparent  that  the  inability  to  retain  impressions  is  dependent 
upon  a  state  of  chronic  alcoholic  delirium.  Besides,  in  acute 
alcoholic  delirium,  the  presence  of  disturbances  of  memory  for 
recent  events  can  always  be  demonstrated,  while  the  memory 
for  events  antedating  the  delirium  remains  intact.  The  cumula- 
tive effect  of  repeated  alcoholic  excesses  and  repeated  attacks  of 
delirium  must  naturally  be  a  constantly  augmenting  disturbance 
in  the  power  of  recollection.  It  is  to  the  marked  restriction  of 
memory  for  recent  occurrences  that  we  must  ascribe  the  dis- 
orientation so  characteristic  of  delirium  tremens,  Korsakoff's 
psychosis  and  senile  dementia. 

Finally,  in  the  diagnosis  of  paresis,  a  test  of  the  memory  for 
recent  events  is  of  supreme  importance.  In  contrast  to  senile 
dementia,  in  which  the  memory  easily  retains  the  events  of  the 
distant  past  while  unable  to  receive  new  impressions,  paresis 
presents  memory  disturbances  covering  the  patient's  entire  life. 
In  many  instances,  however,  the  disorder  of  memory  for  recent 
events  occupies  the  foreground  while  deficiencies  in  the  rest  of 


166     THE  UNSOUND  MIND  AND  THE  LAW 

the  memory-store  are  unimportant.  Hence,  we  have  another 
very  important  symptom  to  aid  us  in  arriving  at  a  definite 
diagnosis. 

Let  us  next  consider  those  disorders  of  the  faculty  of  recollec- 
tion designated  as  "amnesia."  This  term  is  applied  to  a  mem- 
ory defect  that  covers  a  definite,  often  sharply  circumscribed 
period  of  time,  while  the  rest  of  the  memory  contents  remains 
undisturbed.  Amnesia,  being  one  of  the  best  criteria  of  uncon- 
sciousness, is  of  great  forensic  significance.  Persons  who  have 
committed  criminal  acts  frequently  claim  to  have  no  knowledge 
of  what  they  have  done.  Consequently  it  devolves  upon  the  ex- 
pert to  demonstrate  to  what  extent  their  claim  of  amnesis  is 
based  upon  truth. 

Amnesia  is  a  fairly  frequent  symptom.  In  concussion  of  the 
brain  as  a  result  of  a  fall  or  blow,  in  suicidal  attempts  by  means 
of  hanging  or  drowning,  after  poisoning  by  alcohol,  carbonic 
oxide,  ether,  chloroform,  etc.,  as  well  as  after  severe  emotional 
shock,  there  often  sets  in  a  defect  of  memory,  a  gap  that  em- 
braces the  particular  happening  and  the  time  of  its  occurrence. 
In  some  instances  amnesia  lasts  for  hours,  days,  weeks  or  even 
months,  eliminating  the  victim's  knowledge  of  everything  that 
occurs  in  the  interim.  This  interesting  and  puzzling  symptom 
is  designated  as  retrograde  or  retroactive  amnesia. 

Simple  amnesia  is  one  of  the  classic  symptoms  of  epilepsy. 
Its  occurrence  in  this  disease  is  so  frequent  that  any  case  of 
simple  amnesia  must  arouse  a  suspicion  of  epilepsy.  In  every 
typical  epileptic  seizure,  complete  amnesia  for  the  time  of  the 
attack,  and,  therefore,  for  the  spell  itself,  is  encountered.  In 
some  cases  we  may  observe  a  retrograde  amnesia,  usually  cover- 
ing a  few  hours  of  the  time  preceding  the  attack.  Furthermore, 
total  or  partial  amnesia  is  present  in  all  the  epileptic  attacks 
that  manifest  themselves  as  "petit  mal, "  "absences"  and  simple 
transitory  dizziness.  Finally,  amnesia  is  also  a  typical  symptom 
of  the  epileptic  twilight  states  and  epileptic  conditions  of  ex- 
citement. 

The  extraordinarily  important  relations  that  epilepsy  bears  to 
criminal  jurisprudence  are  well  known.  Many  crimes  are  com- 
mitted by  epileptics  when  in  a  state  of  confusion  or  excitement. 
The  old  teaching  that  complete  amnesis  must  exist  in  every 
epileptic   when   the  attack  and   the  state  of  excitement  have 


THE  EXAMINATION  OP  THE  INSANE     167 

passed  away  has  long  been  materially  modified.  In  epilepsy,  in 
fact,  all  possible  grades  and  forms  of  amnesia  may  be  noted.  In 
some  patients  complete  loss  of  recollection  sets  in  after  an  attack 
and  no  measures  will  succeed  in  bridging  the  gap;  in  others, 
single  disconnected  memory  pictures  will  emerge  gradually  from 
the  amnesic  gloom,  but  even  some  of  these  will  again  disappear ; 
in  still  other  patients  there  arises  merely  a  partial  amnesia 
which  occasionally  can  be  diminished  by  refreshing  the  memory 
and  stimulating  the  association  of  ideas. 

What  we  most  often  observe  after  an  epileptic  seizure  is  that 
form  of  amnesia  in  which  recollection  for  the  entire  period  of 
the  psychosis  has  been  preserved  in  a  general  way,  but  is  clouded 
and  disconnected.  The  patient's  estimate  of  the  time  of  dura- 
tion of  the  psychosis  is  usually  most  faulty  and  numerous  mem- 
ory gaps  are  demonstrable.  Hence,  when  a  person  accused  of 
crime  maintains  he  knows  nothing  of  the  acts  attributed  to  him, 
his  statement  must  be  considered  credible  if  it  can  be  shown  he 
has  suffered  from  epileptic  disturbances  of  consciousness.  Many 
convulsive  seizures  naturally  will  pass  unobserved  if  the  patient 
happens  to  be  alone  during  the  attack.  Other  symptoms  then 
must  be  sought  in  order  that  the  diagnosis  of  epilepsy  may  be 
made  with  any  degree  of  certainty.  Sometimes  the  loss  or  cloud- 
ing of  consciousness  precedes  the  attack,  sometimes  it  follows 
and  sometimes  it  occurs  independently  of  any  convulsive  spell. 
From  a  consideration  of  the  attendant  circumstances  the  psy- 
chiatric expert  must  determine  whether  at  the  time  of  a  criminal 
act,  of  which  the  accused  claims  to  know  nothing,  the  latter  was 
in  a  state  of  unconsciousness  or  pathological  perturbation  of 
consciousness  as  a  result  of  which  his  freedom  of  determination 
was  annulled.  Aside  from  the  fact  that  epilepsy,  skull  injuries, 
etc.,  manifest  themselves  by  other  symptoms  in  addition  to  those 
directly  associated  with  the  disturbance  of  consciousness  and  loss 
of  memory,  any  attempt  at  simulation  may  easily  be  recognized 
by  the  contradictions  in  the  simulant's  statements.  Under  per- 
sistent questioning  he  will  reply  now  in  one  way  and  now  in 
another;  and  very  probably  he  will  mention  some  one  thing 
showing  he  well  observed  what  took  place  around  him  at  the 
critical  time.  If  all  recollection  of  the  occurrence  has  been  ob- 
literated contradictions  are  not  so  likely  as  in  the  ease  of  the 
simulant. 


168     THE  UNSOUND  MIND  AND  THE  LAW 

Amnesia  of  varying  intensity  also  occurs  after  hysterical  at- 
tacks, although  much  less  frequently  than  in  epilepsy.  A  con- 
sideration of  the  associated  symptoms  will  easily  enable  us  to 
determine  whether  we  are  dealing  with  an  epileptic  or  with  an 
hysterical  amnesia.  Amnesia  of  every  degree  may  be  en- 
countered after  alcoholic  delirium,  particularly  when  associated 
with  convulsions.  In  some  cases  the  recollection  of  certain 
imaginary  happenings  believed  to  have  taken  place  during  the 
delirium  (dreamy  states)  is  extraordinarily  vivid.  A  retrograde 
amnesia  is  never  observed  in  isolated  instances  of  delirium 
tremens.  Only  after  the  attacks  of  delirium  follow  each  other 
repeatedly  and  often  do  we  meet  with  a  retroactive  amnesia. 
This  may  cover  a  period  of  years  and  may  be  of  such  intensity 
as  to  efface  the  entire  period  completely  from  the  patient's  mem- 
ory. There  often  follows  an  exuberant  activity  of  the  imagina- 
tion known  as  "confabulation,"  which  takes  the  place  of  the 
memory  contents  that  have  been  lost.  In  this  connection  it  may 
not  be  amiss  to  mention  the  artificial  production  of  amnesia,  for 
it  is  possible  by  means  of  suggestion,  without  hypnotism,  to 
eliminate  a  recollection  of  individual  happenings.  In  fact,  it  has 
been  claimed  that  a  complete  loss  of  memory  for  entire  periods 
of  life  may  thus  be  effected.  That  this  question  may  be  of  foren- 
sic interest  will  be  shown  in  the  chapter  of  this  book  that  deals 
with  hypnosis.  Alcoholic  intoxication  may  be  followed  by  per- 
turbation of  consciousness  and  amnesia,  but  no  one  who  commits 
a  crime  while  in  the  state  of  senseless  drunkenness  can  be  freed 
from  responsibility.  Forensieally,  therefore,  a  distinction  must 
be  made  between  the  clouded  consciousness  and  loss  of  recol- 
lection due  to  disease,  and  that  which  has  been  self-induced. 

"We  have  still  to  consider  those  disorders  of  memory  in  which 
the  power  of  recollection  remains  apparently  undisturbed,  but  in 
which  the  memory  contents  are  more  or  less  glaringly  falsified. 
In  such  cases  the  patients  can  well  respond  to  all  questions  not- 
withstanding the  fact  that  their  memories  are  most  defective. 
They  are  able  to  cover  their  loss  of  recollection  by  filling  in  the 
gaps  with  the  confabulations  previously  referred  to.  Then  we 
find  the  memory  contents  replaced  by  free  inventions,  often  of 
the  most  fantastic  kind.  What  the  patient  brings  forth  consti- 
tutes not  his  real  experiences,  but  the  products  of  his  vivid  imag- 
ination.    Naturally  the  physician  must  be  in  possession  of  a 


THE  EXAMINATION  OF  THE  INSANE     169 

trustworthy  anamnesis  in  order  to  be  able  to  determine  which 
of  the  statements  that  do  not  clearly  bear  the  stamp  of  inven- 
tion are  imaginary  and  which  are  actually  true. 

Of  less  significance  diagnostically  are  the  transmutations  that 
paranoiacs  and  melancholiacs  often  give  to  their  memory  images. 
The  melancholiac  looks  upon  his  entire  life  as  a  chain  of  calam- 
itous, sinful  deeds,  every  harmless  escapade  of  his  youth  being 
tinged  by  the  somber  light  of  his  self -accusations  of  wickedness. 
The  paranoiac,  once  his  delusions  have  become  systematized, 
weaves  into  his  past  life  the  existing  ideas  of  persecution  and 
everywhere  discovers  traces  of  the  malevolent  activities  of  his 
enemies.  This  false  interpretation  of  recollection,  often  em- 
bracing the  entire  past  and  termed  "delire  retrograde"  by  the 
French,  is  manifestly  a  logical  deduction  from  the  existing  de- 
lusions. As  the  question  involved  is  one  rather  of  the  false  inter- 
pretation of  actual  experience  than  of  true  memory  defects, 
such  instances  are  termed  illusions  of  memory. 

In  contradistinction,  confabulations  are  designated  as  hal- 
lucinations of  memory.  In  the  latter,  the  existing  memory 
images  are  not  only  transformed  and  interpreted  in  the  sense 
of  a  definite  delusion,  but  they  are  also  embellished  by  pure 
products  of  the  imagination.  In  some  instances  tales  of  sheer 
invention  which  the  patients  believe  to  be  actual  experiences  are 
substituted  for  the  memory  contents  that  have  been  lost.  Such 
confabulations  are  particularly  encountered  in  many  paranoid 
states,  and,  of  course,  are  of  chief  significance  for  diagnosis. 
Very  often  they  are  present  in  true  systematized  paranoia,  but 
more  especially  in  the  end  stages,  when  they  accompany  de- 
lusions of  grandeur.  The  patient  thus  afflicted  will  often  fabu- 
late  the  most  extraordinary  imaginings  and  recount  them  em- 
bellished by  the  most  minute  details  of  time  and  place,  as  though 
they  were  reminiscences  from  his  own  life.  The  confabulations 
of  paranoiacs  almost  always  contain  ideas  of  grandeur  and  per- 
secution. Thus  a  paranoiac  belonging  to  a  German  family  of 
the  working  class  tells  us  he  is  the  son  of  one  of  the  ruling 
families  of  Europe  and  direct  heir  to  the  German  throne,  but, 
owing  to  political  intrigues,  he  has  been  supplanted  and  exiled 
and  now  must  live  as  a  poor  laborer  in  a  foreign  country,  etc. 
This  story  is  elaborated  so  fantastically  as  to  create  the  impres- 
sion that  we  are  dealing  partly  with  paranoiac  interpretations 


170     THE  UNSOUND  MIND  AND  THE  LAW 

of  actual  memory  pictures,  partly  with  pure  invention,  partly 
with  a  falsified  reproduction  of  something  the  man  "has  read  and 
which  has  so  stimulated  his  imagination  that  he  believes  himself 
to  be  the  actual  hero  of  the  story. 

The  confabulations  that  we  meet  in  the  paranoid  forms  of 
dementia  precox  are  dominated  entirely  by  the  imagination. 
Their  contents  are  so  silly  and  impossible  that  there  cannot  be  a 
moment's  doubt  regarding  the  diagnosis.  One  patient  may  say 
he  lived  three  thousand  years  ago;  another  that  he  sailed  the 
seas  with  Columbus,  was  drowned  in  the  Atlantic,  resuscitated 
and  given  a  new  lease  of  life  in  order  that  he  might  discover  the 
North  Pole;  and  still  another  has  experienced  the  most  fearful 
adventures,  has  fought  with  dragons  and  has  taken  an  active 
part  in  all  historical  events  of  ancient  and  mediaeval  times.  All 
these  things  are  expounded  with  the  greatest  picturesqueness 
and  vivacity,  just  as  though  it  were  quite  impossible  for  them 
to  have  been  otherwise. 

Confabulations  are  also  encountered  in  those  psychoses  in 
which  marked  memory  defects,  especially  for  recent  events,  are 
present — particularly  in  general  paresis.  In  some  of  these  cases 
confabulations  may  for  a  long  time  dominate  the  entire  picture 
of  disease  and  leave  no  doubt  regarding  their  paretic  nature. 
The  fantastic  adventures  and  experiences,  the  weakminded 
vaporings  of  the  paretic,  are  all  placed  in  the  far  distant  or  in 
the  most  recent  past.  He  has  withstood  the  audacious  attacks  of 
pirates  or  wild  beasts,  has  overcome  countless  enemies,  lived 
upon  other  planets,  accomplished  the  most  prodigious  deeds,  etc. 
The  confabulations  are  very  similar  to  those  of  the  paranoid 
form  of  dementia  prsecox,  and  in  order  not  to  confound  the 
two  diseases  the  other  symptoms  of  paresis  must  be  carefully 
sought. 

Confabulations  occur  in  delirium  tremens,  but  those  never 
relate  to  a  time  antedating  the  onset  of  the  delirium.  The  bal- 
ance of  the  memory  contents  remains  intact  and  unaltered.  A 
person  in  alcoholic  delirium  need  only  be  asked  a  simple  ques- 
tion— why  his  feet  are  bare,  why  he  is  clad  only  in  a  shirt,  where 
he  has  left  his  shoes,  what  his  wife  and  family  are  doing — and 
he  will  promptly  give  a  precise  answer  that  clearly  bears  the 
stamp  of  concoction,  a  lie  made  up  to  meet  the  emergency.  In 
chronic  alcoholic  delirium  (Korsakoff's  Disease)  confabulations 


THE  EXAMINATION  OF  THE  INSANE     171 

are  as  typical  and  cardinal  as  are  the  disorders  of  memory  for 
recent  events.  While  in  the  acute  delirium  of  alcoholism  the 
loss  of  memory  covers  only  the  period  of  the  delirium,  in  the 
chronic  form  of  delirium  we  encounter  a  retrograde  amnesia,  in 
accordance  with  which  the  confabulations  are  naturally  more 
extended.  A  parallelism  between  the  disorders  of  memory  and 
the  confabulations  can  be  discerned  in  all  cases.  In  chronic  alco- 
holic delirium  we  find  upon  the  one  hand  emergency  confabula- 
tions similar  to  those  of  acute  delirium  and  upon  the  other  those 
that  are  analogous  to  the  feebleminded  boastings  of  the  paretic. 
The  differential  diagnosis  between  this  chronic  delirium  and 
paresis  frequently  is  not  easy,  but  it  can  always  be  made  from 
the  history  of  the  course  of  the  disease  when  it  is  not  possible 
to  do  so  from  the  clinical  symptoms  themselves. 

Associated  with  marked  restriction  of  memory  for  recent 
events  confabulations  are  often  also  present  in  senile  dementia, 
creating  a  condition  which  may  so  resemble  Korsakoff's  syn- 
drome as  to  warrant  the  symptomatic  designation  ' l  senile  Korsa- 
koff's  Psychosis."  Patients  thus  afflicted  believe  themselves  to 
be  taking  long  journeys,  think  their  bed  is  a  railroad  carriage, 
undergo  the  most  adventuresome  experiences  and  recount  them 
with  the  most  astonishing  vividness. 

In  contradistinction  to  dementia  senilis  and  the  other  psy- 
choses we  have  mentioned,  in  which  the  confabulations  represent 
illusions  and  hallucinations  of  the  memory,  there  also  exist 
psychic  disturbances  in  which  the  confabulations  are  not  the 
result  of  defects  of  memory  and  which  in  some  instances  are  not 
even  dependent  upon  intellectual  defects.  Thus  manic  patients 
have  a  tendency  to  boast  of  the  extraordinary  occurrences  in 
which  they  have  taken  part.  Here  there  is  no  question  of  falsi- 
fication of  memory,  for  the  patients  well  know  that  the  experi- 
ences they  relate  have  never  taken  place.  Their  confabulations 
are  essentially  an  expression  of  their  exalted  mood  and  are 
evolved  for  the  purpose  of  impressing  their  auditors.  Such 
patients  are  happy  when  they  find  a  listener  willing  to  accept 
their  statements  at  their  face  value. 

There  is  a  large  number  of  individuals  in  whom  the  symptoms 
of  fabulation  are  permanently  present  and  represent  a  trait  of 
character.  Such  confabulations  form,  so  to  speak,  a  constitu- 
tional  anomaly  upon  a  psychopathological  or  hysteric  basis.    AH 


172     THE  UNSOUND  MIND  AND  THE  LAW 

gradations  of  these  anomalies  are  met  with — unpremeditated 
slight  alteration  of  individual  occurrences,  purposeful  misstate- 
ments, a  blending  of  fiction,  truth  and  falsehood,  and  grotesque 
deliberate  deceit.  There  exist  many  persons  who  are  entertain- 
ing, whose  imagination  is  so  fertile  that  every  occurrence  which 
they  relate  undergoes  a  most  artistic,  poetic  and  interesting 
transformation.  Such  pathological  tricksters  may  be  harmless 
or  they  may  be  a  danger  to  the  community.  In  the  latter  class 
we  find  those  international  adventurers  who  often  play  a  certain 
role  in  society,  remain  unexposed  for  a  long  time  and  finally  end 
their  careers  in  prison  or  in  an  asylum.  The  cunning  with 
which  such  individuals  are  able  to  deceive  those  about  them  pre- 
cludes the  existence  of  any  intellectual  defect.  They  never  in- 
vent stories  that  are  manifestly  untrue,  but  they  know  well  how 
to  intertwine  actual  and  fictitious  happenings  so  that  they  will 
appear  credible,  or  at  least  possible,  even  to  the  critical  listener. 
It  is  certain  at  any  rate  that  the  confabulations  of  such  indi- 
viduals should  not  in  all  instances  be  characterized  as  purposeful 
falsehoods ;  often  enough  they  themselves  believe  in  their  patho- 
logical impositions,  which  not  infrequently  represent  the  outcome 
of  their  devotion  to  novels  and  newspapers.  The  question  of 
legal  responsibility  in  such  cases  can  be  determined  alone  by  the 
presence  or  absence  of  other  pathological  symptoms.  "Where 
such  symptoms  are  unmistakably  present  we  must  also  expect 
to  find  so  high  a  degree  of  moral  deficiency  that  at  least  a  re- 
striction of  free  determination  of  the  will  should  be  assumed. 
In  the  absence  of  such  symptoms  no  other  conclusion  is  ad- 
missible than  that  we  are  dealing  with  an  ordinary  adventurer 
and  criminal  who  is  fully  responsible  for  his  illegal  acts. 

As  a  matter  of  fact,  our  criminal  laws  do  not  apply  to  the  con- 
fabulations of  insane  persons,  but  cover  only  those  harmful  ones 
of  people  of  sound  mind.  Under  no  circumstances  should  we 
lose  sight  of  the  fact  that  lying  and  trickery  must  be  consid- 
ered pathological  only  when  they  are  the  product  of  illusions  and 
hallucinations  of  memory.  Evil  may  result  from  confabulations 
not  only  because  they  deceive  and  defraud  credulous  persons,  but 
also  because  they  result  in  the  disgrace  of  innocent  parties.  Par- 
ticularly dangerous  in  this  regard  are  the  slanderous  accusa- 
tions made  by  hysterics  against  physicians  and  others  in  which 
they  maintain  that  they  have  been  sexually  insulted  or  assaulted. 


THE  EXAMINATION  OF  THE  INSANE     173 

Frequently  these  accusations  are  nothing  but  pure  invention, 
embellished  by  fantastic  enlargement,  staged  for  the  purpose  of 
satisfying  personal  sensational  lust.  Such  cases  must  be  differ- 
entiated from  those  in  which  abnormal  sensations  in  the  genital 
sphere  are  the  cause  of  the  accusations,  the  latter  in  such  in- 
stances being  made  in  good  faith.  In  contrast  to  conscious  con- 
fabulations there  are  also  the  false  accusations  made  by  epilep- 
tics and  alcoholics  as  a  result  of  their  illusions  and  hallucina- 
tions. In  their  delirium  such  patients  often  believe  themselves 
to  be  threatened  or  attacked  and  have  actual  struggles  with 
imaginary  individuals ;  and  when  these  sense  disorders  have  dis- 
appeared and  they  have  become  mentally  clear,  they  are  still 
firmly  convinced  of  the  reality  of  the  attacks.  This  accounts  for 
false  accusations  against  physicians,  nurses  and  other  people  in 
their  surroundings.  On  the  other  hand,  the  patients  sometimes 
continue  to  believe  in  the  evil  deeds  or  crimes  which  they  recol- 
lect having  committed  in  their  delirious  state,  and  then  they  go 
to  a  police  station  to  give  themselves  up  because  of  the  hal- 
lucinated crimes.  "Where  the  facts  are  known  and  where  the 
anamnesis  shows  an  epileptic  or  alcoholic  delirium  to  have  pre- 
ceded such  self -accusations,  it  should  not  be  difficult  to  recognize 
the  true  state  of  affairs. 


0.      THE  INTELLIGENCE  AND  JUDGMENT 

As  we  have  seen,  the  confabulations,  false  accusations  and 
other  misleading  statements  made  by  mentally  disordered  indi- 
viduals differ  chiefly  from  those  of  mentally  healthy  persons  in 
that  they  are  the  product  of  sense  deceptions,  loss  of  recollection 
and  other  disturbances  of  memory.  Hence  a  test  of  the  memory 
is  not  only  diagnostically  but  also  forensically  of  great  impor- 
tance, for  its  results  permit  us  to  conclude  definitely  whether  any 
warrant  exists  for  the  assumption  that  an  accused  individual  has 
suffered  from  a  clouding  of  consciousness  and  loss  of  recollec- 
tion. Of  equal  importance  is  the  test  of  the  intelligence,  which 
we  shall  now  consider.  From  the  conversation  with  the  patient, 
from  the  anamnesis  the  patient  himself  gives,  it  will  not  be  dif- 
ficult for  the  examining  physician  to  obtain  a  fairly  clear  impres- 
sion of  his  general  intelligence  and  to  determine  whether  he  is 
cultured  or  uncultured,  talented  or  feebleminded.    Nevertheless 


174     THE  UNSOUND  MIND  AND  THE  LAW 

important  intellectual  defects  may  exist  that  hitherto  have 
passed  unobserved.  By  means  of  a  test  of  the  intelligence,  the 
physician  endeavors  to  obtain  as  complete  an  inventory  as  pos- 
sible of  the  patient's  mental  acquirements — particularly  in 
forensic  cases  in  which  it  is  important  to  understand  the  entire 
psychic  life  of  the  accused  individual.  It  is  less  important  to 
determine  the  extent  of  knowledge  the  subject  may  have  acquired 
than  to  ascertain  the  degree  of  his  independent  power  of  judg- 
ment. In  order  that  nothing  may  be  overlooked  in  making  the 
examination  a  certain  plan  must  be  followed,  and  it  will  be  well 
to  make  use  of  the  methods  most  generally  in  vogue.  It  is  im- 
possible to  draw  a  sharp  dividing  line  between  an  intelligence 
test  and  a  memory  test.  Inasmuch  as  all  judgment  is  dependent 
upon  association  of  sensory  impression — that  is,  of  the  memory 
pictures  of  those  impressions  that  have  been  retained — the  circle 
of  ideas  will  necessarily  become  restricted  when  memory  has  been 
lost,  and  this  restriction  cannot  fail  to  react  upon  the  power  of 
judgment.  In  fact,  therefore,  intelligence  tests  and  memory  tests 
cover  the  same  grounds;  but  this  by  no  means  implies  that  a 
parallelism  exists  between  memory  and  intelligence.  Not  infre- 
quently we  find  persons  with  extraordinary  memories,  persons 
who  never  forget  what  they  have  heard  or  read,  but  who  intel- 
lectually stand  upon  a  very  inferior  plane,  their  power  of  judg- 
ment not  being  sufficient  to  enable  them  to  connect  logically  and 
purposefully  the  things  they  have  heard  and  read.  On  the  other 
hand  a  person's  memory  may  be  very  bad  and  still  he  may  have 
an  excellent  power  of  judgment.  Hence,  memory  and  intelli- 
gence can  never  serve  as  gages  of  each  other.  Let  us  exemplify 
this.  Two  patients  are  requested  to  compose  a  letter,  an  auto- 
biography or  an  essay  upon  a  given  subject.  One  will  submit  a 
production  that  is  grammatically  correct,  while  the  other's  is 
replete  with  errors.  From  this  fact  alone  it  would  be  a  mistake 
to  conclude  that  the  former  occupies  a  high  plane  of  intelligence 
and  the-  other  a  low  one.  The  first  patient  has  had  a  high-school 
education  and  the  rules  of  grammar  have  remained  fixed  in  his 
memory,  but  the  other,  having  had  but  a  sparse  schooling,  has 
learned  no*  grammar  at  all.  "What  the  latter  man  writes,  how- 
ever, is  purposeful  and  logical,  while  the  writing  of  the  other 
despite  his  correctness  is  irrelevant  and  nonsensical.  This  shows 
that  no  test  of  the  intelligence  can  be  of  value  unless  a  careful 


THE  EXAMINATION  OF  THE  INSANE     175 

consideration  is  given  to  the  patient's  social  position  and  educa- 
tional opportunities.  The  diagnostic  significance  of  grammatical 
errors  in  a  written  composition,  ignorance  of  the  laws  of  physics, 
anachronisms  regarding  important  historical  events,  etc.,  will 
vary  extremely  in  accordance  with  the  patient's  educational  ad- 
vantages. When  such  mistakes  are  encountered  in  patients  of 
little  education,  they  can  by  no  means  be  construed  as  evidences 
of  intellectual  weakness,  but  in  a  person  of  college  training  they 
represent  positive  evidence  of  intellectual  decline.  The  decision 
must  always  rest  on  a  comparison  of  the  present  psychic  com- 
portment and  that  previously  existing.  A  person  who  has  grown 
up  in  ignorance  divulges  his  pathological  intellectual  weakness 
by  the  inability  to  combine  into  orderly  relations  those  notions 
that  accord  with  his  state  of  education,  and  which  are  aroused 
by  the  impressions  produced  by  things  about  him.  In  a  person  of 
greater  culture  the  decay  of  mental  power  will  manifest  itself 
partly  by  a  progressive  loss  of  the  knowledge  he  has  acquired, 
partly  by  an  increasing  disturbance  of  judgment  and  orderly 
thought.  The  evidence  needed  to  determine  the  diagnosis  is  fur- 
nished not  by  a  comparison  with  other  individuals,  but  by  com- 
paring the  patient's  intellectual  self  with  what  he  was  before  the 
onset  of  the  disease.  The  disability  of  judgment  is  produced  be- 
cause certain  percepts  are  only  superficially  anchored  in  the 
memory  store,  have  not  been  mentally  assimilated,  and,  there- 
fore, cannot  be  associatively  combined. 

Being  obliged  to  deal  with  patients  of  every  degree  of  intelli- 
gence and  education,  the  alienist,  and  more  especially  the  foren- 
sic psychiatrist,  should  possess  an  extended  practical  knowledge 
of  people  and  things  and,  in  particular,  should  be  able  to  compre- 
hend all  possible  phases  of  another  person's  mind  and  to  place 
himself  in  all  possible  situations  of  daily  life.  Only  in  this  man- 
ner will  he  be  able  to  estimate  the  mentality  of  the  patients,  to 
appreciate  their  powers  of  judgment  and  to  understand  what 
part  of  their  intellect  has  been  affected  and  what  part  has  re- 
mained undisturbed.  The  main  difficulty,  therefore,  will  be 
found  in  the  selection  of  those  problems  that  are  to  constitute  the 
means  for  testing  the  intelligence  in  such  a  manner  that  justice 
may  be  done  to  all  grades  of  individuals  and  to  the  most  varied 
phases  of  human  mental  activity. 

An  excellent  method  for  estimating  the  degree  of  a  person's 


176     THE  UNSOUND  MIND  AND  THE  LAW 

intelligence  is  the  so-called  association  test.  This  is  based  upon 
the  fact  that  association  of  ideas  represents  the  most  elementary 
as  well  as  the  most  significant  manifestation  of  psychic  life  and  is 
looked  upon  by  modern  psycho-physics  as  the  prime  principle  of 
all  psychic  happenings.  I  cannot  here  enter  into  details  of  that 
newer  association  psychology  with  which  every  psychiatrist 
should  be  fully  conversant.  The  jurist  also  should  be  so  well 
acquainted  with  "Wundt's  association  laws  that  the  significance  of 
the  association  processes  will  be  clear  to  him.  Briefly  stated,  the 
association  test  is  based  primarily  on  the  selection  of  a  number  of 
words  adapted  to  the  patient's  grade  of  culture.  These  words 
are  called  ' '  stimuli. ' '  When  a  peasant  hears  the  word  ' '  corn, ' '  a 
blacksmith  the  word  "hammer,"  a  philosopher  the  word 
"Plato,"  etc.,  the  association  activities  of  the  respective  indi- 
viduals are  aroused,  and  each  will  give  expression  to  the  first 
thought  brought  to  his  mind  by  the  particular  "word  stimulus." 
The  association  test  for  an  evaluation  of  the  intelligence  may 
be  divided  into  two  parts — a  general  and  a  special  one.  The  gen- 
eral part  is  that  designated  as  the  statistic  method  for  the  com- 
putation of  the  association  breadth.  This  method  is  applied  as 
follows : 

"We  take  a  schedule  of  one  hundred  different  words  which  de- 
note all  kinds  of  objects  and  their  properties.  These  different 
excitation  words  are  uttered  in  a  loud  voice,  the  patient  being 
required  to  tell  at  once  what  associations  are  produced  in  his 
mind  by  each  one.  After  a  lapse  of  at  least  four  weeks,  this  pro- 
cedure is  repeated.  The  reactions  obtained  after  each  test  hav- 
ing been  carefully  noted,  we  can  by  calculation  derive  from  them 
the  number  which  we  designate  as  the  association  breadth,  i.  e., 
the  percentage  that  expresses  the  number  of  different  reactions 
(associations)  that  will  result  from  one  hundred  different  word 
stimuli. 

In  very  intelligent  and  cultured  persons  these  one  hundred 
word  stimuli  at  the  very  first  test  usually  call  forth  ninety-five  to 
one  hundred  different  associations;  in  less  intelligent  persons  and 
in  feeble-minded  patients,  even  at  this  very  first  test,  the  same 
reaction  will  be  found  to  recur  again  and  again.  The  second  test 
is  far  more  important  than  the  first  one,  for  only  then  does  the 
difference  in  the  extent  of  the  perceptual  store  become  apparent. 
The  mentally  superior  person  will  not  need  to  revert  to  the 


THE  EXAMINATION  OF  THE  INSANE     177 

associations  that  were  produced  in  him  by  the  first  test,  but  will 
bring  forth  new  reactions.  In  the  feeble-minded  person,  on  the 
other  hand,  the  control  test  will  cause  more  or  less  repetition  of 
the  associations  evolved  by  the  first  test. 

The  association  breadth  thus  determined  is,  therefore,  a  fairly 
accurate  measure  of  a  patient's  intelligence  and  cultural  de- 
velopment. In  general  the  association  breadth  of  an  adult  may 
be  taken  to  be  about  80  to  90%.  "Whenever  the  figure  falls  to 
70%  we  are  justified  in  suspecting  the  existence  of  intellectual 
weakness.  Where  the  association  breadth  is  60%  or  less,  there 
can  be  no  doubt  of  its  pathological  significance,  even  if  a  higher 
figure  was  obtained  in  the  first  test,  as  is  often  the  case  in  people 
of  slight  intelligence. 

By  means  of  this  test,  therefore,  we  are  able  to  establish  an  ap- 
proximate numerical  index  for  the  degree  of  existing  intelligence 
or  feeble-mindedness.  The  method  is  applicable  to  most  patients 
■ — to  idiots  and  feeble-minded,  to  maniacs,  melancholiacs,  para- 
noiacs,  paretics,  and  even  to  those  in  a  state  of  alcoholic  de- 
lirium or  epileptic  confusion.  Of  course  this  does  not  signify 
that  other  methods,  such,  for  instance,  as  the  Binet-Simon  test, 
may  not  be  quite  as  serviceable  or  even  more  serviceable  in  indi- 
vidual cases.  As  a  matter  of  fact,  all  methods  for  the  evaluation 
of  intelligence  are  to  a  greater  or  less  extent  association  tests. 

Whether  the  forensic  psychiatrist 's  task  be  to  demonstrate  the 
insanity  of  a  person  claimed  to  be  sane,  or  to  prove  the  insanity 
of  a  person  simulating  mental  disorder,  the  examination  of  the 
intelligence  cannot  well  be  dispensed  with.  Association  tests 
will  furnish  us  with  the  following  information  that  may  be  of 
value  in  differential  diagnosis: 

1.  In  paresis,  frequently  very  early,  a  remarkably  low  associ- 
ation breadth,  one  which  does  not  harmonize  with  the  person's 
degree  of  education,  may  be  determined.  Moreover,  the  re- 
sponses of  the  paretic  are  often  markedly  retarded,  and  are  pro- 
duced only  with  effort,  after  a  distressful  and  embarrassed 
search.  It  is  also  characteristic  of  paretics  who  in  current  con- 
versation talk  freely  and  easily  that  they  become  uncertain  and 
helpless  as  soon  as  they  are  given  a  definite  task  to  carry  out. 
The  same  result  manifests  itself  when  an  attempt  is  made  by 
means  of  a  word  stimulus  to  call  their  association  processes  into 
activity. 


178     THE  UNSOUND  MIND  AND  THE  LAW 

2.  The  bizarreries  of  katatonics  will  often  become  manifest 
in  their  associations.  Some  of  them  will  show  a  marked  prefer- 
ence for  contrasting  ideas — for  instance,  in  responding  to  the 
stimulus  word  "hot,"  by  immediately  talking  of  something  be- 
longing to  the  category  of  cold.  Such  reactions  may  be  looked 
upon  as  negativistic  associations.  Occasionally  also  katatonics 
will  react  to  entirely  different  stimuli  by  one  and  the  same 
answer.  In  individual  cases  this  may  go  so  far  that,  throughout 
the  entire  test,  one  and  the  same  association  is  constantly  reit- 
erated in  a  monotonous  tone  of  voice.  Similarly  new  word  con- 
structions, speech  distortions  and  paralogisms  may  be  obtained 
in  response  to  the  association  tests. 

3.  In  the  maniac,  when  an  association  test  is  at  all  possible, 
flight  of  ideas  may  easily  be  demonstrated.  No  sooner  has  the 
stimulus  word  been  uttered  than  it  is  followed,  with  extraor- 
dinary rapidity,  by  an  entire  chain  of  different  reactions,  the 
end  link  of  which  bears  no  relation  whatsoever  to  the  original 
stimulus  word.  In  the  maniac  there  will  also  be  found  tone 
associations,  produced  essentially  by  the  sound  of  the  stimulus 
word,  and  not  by  its  meaning,  as,  for  instance,  "dog-fog," 
" '  daughter- water, ' '  etc. 

4.  In  epileptic  patients  the  associations  elicited  by  the  test 
must  be  considered  entirely  by  themselves  and  independently  of 
the  stimulus  word.  In  many  instances  they  will  lay  bare  the 
whole  pathological  character  of  the  epileptic,  his  egotism,  his  ex- 
aggerated religiosity,  his  tendency  to  pedantry  and  to  rambling 
discursiveness.  In  epileptic  feeble-mindedness  the  statistical 
method  will  give  us  an  indication  of  the  existing  degree  of  de- 
mentia and  this  often  will  be  found  to  be  much  greater  than 
would  apriori  have  been  surmised. 

5.  Idiots  usually  show  more  aptness  in  association  tests  than 
would  be  expected.  Of  course  the  association  breadth  will  be 
very  limited,  usually  below  40%,  decreasing  to  zero  in  accord- 
ance with  the  degree  of  intelligence.  More  recently  a  large  num- 
ber of  investigators  has  preferred  to  use  the  Binet-Simon  test 
for  determining  the  fluctuations  in  the  association  breadth  of 
idiots  and  imbeciles.  This  test  consists  in  the  selection  of  a  num- 
ber of  questions  which  correspond  to  the  normal  judgment  at  dif- 
ferent ages.  The  subjects  of  the  test  are  then  grouped  in  ac- 
cordance with  their  intelligence  and  not  in  accordance  with  their 


THE  EXAMINATION  OF  THE  INSANE     179 

ages.  If,  for  instance,  the  subject  is  eighteen  years  of  age,  but 
can  answer  only  such  questions  as  correspond  to  the  intellectual 
grade  of  a  child  twelve  years  old,  this  person  will  be  classified,  in 
accordance  with  the  Binet-Simon  age,  as  twelve  years  of 
age. 

In  addition  to  the  established  invariable  schedule  of  one  hun- 
dred excitation  words  used  for  the  statistic  computation  of  the 
association  breadth,  certain  cases  will  require  the  employment  of 
a  specially  arranged  schedule  containing  excitation  words  which 
will  inform  us  concerning  the  processes  that  momentarily  exist. 
In  such  instances  it  is  a  question  of  obtaining  material  for  dif- 
ferential diagnosis  as  well  as  for  the  establishment  of  the  indi- 
vidual psychology.  The  entire  test,  then,  is  a  disguised  search 
for  pathological  conditions.  Such  word  stimuli  as  "enemies," 
"voices,"  "president,"  "millionaire,"  which  are  related  to  de- 
pressive or  expansive  delusions,  will  often  call  forth  very  inter- 
esting reactions  when  unobtrusively  interspersed  among  other 
word  stimuli  of  indifferent  significance. 

Equally  dependent  upon  the  principle  of  individual  psychology 
is  the  method  of  submitting  individual  capabilities  of  a  patient 
to  a  closer  test.  According  to  his  station  and  culture  he  may  be 
asked  to  write  a  short  dissertation  upon  some  historical,  theo- 
logical, geographical,  philosophical,  literary  or  technical  subject, 
upon  a  topic  of  the  day,  political,  economical,  occupational  or 
otherwise.  Or  the  patient  may  be  verbally  questioned  regarding 
matters  in  which  he  is  interested  most,  or  which  take  up  the 
greater  part  of  his  time.  In  this  manner  it  is  often  possible  to 
determine  that  a  certain  talent,  possibly  that  for  arithmetic,  or 
drawing,  or  music,  is  preeminently  developed,  while  other  psy- 
chic attainments  have  remained  so  backward  that  the  intelligence 
and  breadth  of  association  are  below  the  average. 

Naturally  there  are  many  methods  in  addition  to  those  out- 
lined. Every  experienced  psychiatrist  will  be  able  to  elaborate 
variations  of  the  methods  we  have  mentioned,  in  order  to  meet 
the  requirements  of  special  and  unusual  cases.  Of  course,  the 
examination  cannot  and  need  not  be  carried  out  in  every  case 
precisely  as  we  have  described  it.  Special  attention  should  be 
drawn  to  the  fact  that  the  question  whether  the  patient  does  or 
does  not  recognize  he  is  sick  can  by  no  means  be  made  to  form 
any  part  of  his  intelligence  test.    This  question,  in  fact,  is  of  no 


180     THE  UNSOUND  MIND  AND  THE  LAW 

practical  import,  inasmuch  as  insane  patients,  with  few  excep- 
tions, have  only  a  very  vague  appreciation,  if  any,  of  their  ill- 
ness. When  they  do  appreciate  it,  we  have  an  important  symptom 
of  beginning  or  complete  recovery,  and  hence  this  is  of  value 
only  for  prognosis  and  not  for  diagnosis. 


Part  Second 
PSYCHIATRIC  EXPERTISM 


SPECIAL  DIAGNOSTICS  OF  MENTAL  DISORDERS 

The  bodily  and  psychic  examination  described  in  the  fore- 
going pages  furnishes  merely  the  general  basis  for  an  expert 
opinion  of  a  concrete  case.  We  will  now  see  how  the  material 
derived  from  the  examination  of  the  patients  may  be  elaborated 
so  as  to  constitute  an  exact  diagnosis.  In  forensic-psychiatric 
expertism  it  is  especially  important  to  submit  the  results  of  the 
examination  to  the  judge  in  such  form  that  he  will  obtain  a 
sufficiently  clear  insight  into  the  nature  of  the  doubtful  mental 
state  to  enable  him  to  arrive  at  a  correct  decision.  The  diagnosis 
may  be  scientifically  correct,  but  be  valueless  for  that  purpose 
because  not  in  proper  form,  or  else,  while  correct  as  to  form,  it 
may  be  entirely  inadequate  in  a  scientific  sense.  Equal  care 
should  be  given  to  both  details. 

Let  us  now  proceed  to  a  consideration  of  the  special  diag- 
nostics. 


I 

PSYCHOSES  IN  GENERAL 

1.   Paresis 

One  of  the  most  variable  of  psychoses,  hence  often  most  diffi- 
cult to  diagnose,  is  paresis,  popularly  known  as  softening  of  the 
brain.  It  is  a  chronic  incurable  progressive  insanity  that  leads 
to  complete  dementia,  is  accompanied  in  its  course  by  signs  of 
organic  lesion,  affects  mainly  persons  of  middle  age  (thirty-five 
to  forty-five  years),  and  generally  ends  in  death  after  a  few 
years.  In  nearly  all  cases,  either  by  means  of  the  previous  his- 
tory or  of  the  "Wassermann  test,  it  may  be  shown  that  syphilis 
was  present,  and  for  that  reason  it  may  now  be  said  with  con- 
fidence that  paresis  is  a  result  of  syphilitic  infection.  Since  the 
discovery  by  Noguchi  and  Moore  of  spirochetes  in  twelve  out 
of  seventy-five  brains  of  general  paralytics,  a  discovery  con- 
firmed by  many  observers,  all  doubt  as  to  the  essential  cause  of 
the  disease  has  been  dispelled.  In  a  series  of  one  hundred  brains 
of  persons  dying  from  paresis  Mott  has  found  the  spirochetes 
in  sixty-six.  They  exist  scattered  all  over  the  gray  matter  of 
the  cortex,  but  can  be  found  more  especially  over  the  frontal 
lobes.  If  the  preparation  is  made  soon  after  death,  the  organ- 
isms can  be  seen  moving.  In  practically  every  case  of  general 
paralysis  the  spinal  fluid  gives  a  positive  Wassermann  reaction. 
Sometimes  the  disease  sets  in  during  childhood  as  a  result  of  in- 
herited lues.  Of  sixty  juvenile  paretics  he  had  collected,  Mott 
says  that  twenty  per  cent  had  one  parent  who  was  a  paretic, 
usually  the  father.  Conjugal  paresis  also  has  been  observed. 
Men  are  affected  three  or  four  times  as  often  as  women.  The 
paretic  destructive  process  may  be  hidden  under  the  mask  of  a 
maniacal,  melancholiac,  paranoid  or  other  state  of  disease, 
making  a  positive  diagnosis  very  difficult. 

On  account  of  the  very  frequent  occurrence  of  paresis,  its  ab- 
solutely unfavorable  prognosis,  and  the  many  dangers  involved 
for  the  family  of  the  patient,  the  early  recognition  of  this  psy- 

183 


184     THE  UNSOUND  MIND  AND  THE  LAW 

chosis  is  of  eminent  importance.  A  positive  Wassermann  reaction 
of  the  blood  and  spinal  fluid,  an  increased  cell  count  and  an 
increased  globulin  reaction  of  the  spinal  fluid  render  early  recog- 
nition fairly  certain.  The  value  the  Abderhalden  sero-diagnosis 
test  may  have  in  this  regard  cannot  as  yet  be  determined.  But 
even  without  the  aid  of  newer  methods  of  investigation  a  precise 
diagnosis  can  often  be  made  in  the  very  early  stages.  In  the 
majority  of  instances  there  are  present,  in  addition  to  decided 
increasing  mental  weakness,  certain  typical  symptoms  of  nerve 
irritation  and  loss  of  function.  Wherever  a  psychosis  occurring 
in  middle  age  presents  the  typical  nerve  symptoms  of  a  large 
number  of  signs  of  nerve  irritation — there  must  be  an  immediate 
suspicion  that  paresis  is  developing.  Not  all  nerve  symptoms 
are  of  equal  value  for  the  diagnosis  of  this  disease,  but  there  are 
three  which,  if  associated  with  any  sign  of  mental  disorder,  are 
almost  positive  indications.     These  are: 

(1)  Pupilary  Disorders.  The  pupils  may  be  either  abnor- 
mally small  (myosis)  or  extraordinarily  large  (mydriasis)  ;  often 
inequality  of  the  pupils  or  an  irregularity  in  contour  of  one 
pupil  exists.  The  reaction  to  light  may  be  sluggish  or  lost  upon 
one  or  both  sides,  while  the  reaction  to  accommodation  is  re- 
tained (Argyll-Robertson  pupil). 

(2)  Defective  Response  of  Knee  Jerks.  The  response  of  one 
or  both  knee  jerks  or  foot  jerks  may  be  absent  or  reduced. 

(3)  Disorders  of  Speech.  The  speech  becomes  hesitating  or 
stumbling,  and  often  very  early  acquires  a  nasal  character. 

These  three  nerve  symptoms  are  most  often  present  at  an  early 
stage  of  the  disease.  Optic  nerve  atrophy  may  also  be  an  early 
symptom.  While  its  occurrence  in  paresis  is  not  frequent,  it 
will,  when  present,  serve  to  corroborate  an  otherwise  doubtful 
diagnosis.  Hence  it  may  be  said  that  every  mental  disorder 
occurring  in  a  middle-aged  person  and  characterized  by  progres- 
sive diminution  of  mental  powers,  together  with  reflex  rigidity 
of  the  pupils,  absence  of  one  or  both  knee  jerks,  and  disorders  of 
speech  or  optic  atrophy,  should  be  diagnosed  as  paresis. 

In  addition  to  these  cardinal  symptoms,  however,  there  are 
others  which,  when  associated  with  psychic  weakness,  indicate 
the  existence  of  paresis.  The  latter  point  to  affections  of  the 
most  varied  organs  and  parts  of  the  body,  and  may  be  classified 
as  follows: 


PSYCHOSES  IN  GENERAL  185 

(A)  Disorders  of  motility.  Tremor  of  the  extended  and  ab- 
ducted fingers,  tremor  of  the  tongue  as  well  as  in  the  rest  of  the 
musculature  of  the  body,  unequal  facial  innervation  (slight 
facial  paralysis),  ataxia  of  the  extremities,  swaying  of  the  body 
with  the  eyes  closed,  and  reduced  muscular  power  (grasp  of  the 
hand).  Very  characteristic  signs  are  pronounced  difference  in 
the  innervation  of  the  two  sides  of  the  body,  ptosis,  strabismus 
and  weakness  or  paralysis  of  the  eye  muscles.  Especially  fre- 
quent are  those  peculiarities  of  innervation  of  the  mimic  mus- 
culature known  as  "associated  movements." 

(B)  Disorders  of  sensibility.  In  the  beginning  of  a  paresis, 
neuralgia,  severe  headaches  and  lancinating  pains  in  the  legs 
are  often  present.  Frequently  also  there  is  a  reduction  or  loss 
of  sensibility  in  the  lower  extremities. 

(C)  Disorders  of  the  nerves  of  special  sense.  The  sense  of 
smell  is  often  lost,  that  of  taste  less  frequently. 

(D)  Disturbances  in  the  handwriting.  Tremorous,  ataxic  and 
paralytic  writing. 

(E)  Disturbances  in  reading.  These  often  occur  at  a  time 
when  speech  disturbances  are  as  yet  merely  indicated.  The 
patients  no  longer  comprehend  written  characters  and,  there- 
fore, interpret  them  falsely.  In  addition  to  the  errors  made  in 
reading,  more  or  less  gross  mistakes  in  talking  are  also  made. 

(F)  Disordered  reflexes.  The  absence  of  knee  jerks,  foot  jerks 
and  pupilary  reflexes  has  already  been  mentioned  under  the 
cardinal  symptoms.  Not  infrequently  the  knee  jerks  are  mark- 
edly reduced;  very  often  they  are  over-active  and  then  a  foot 
clonus  is  obtainable.  Sometimes  in  the  beginning  of  a  paresis 
the  knee  jerks  are  strongly  increased,  but  they  become  weaker 
and  weaker  until  they  finally  disappear.  Another  characteristic 
is  an  inequality  of  the  reflexes  of  both  sides,  so  that  a  reflex  upon 
the  one  side  may  be  markedly  greater  or  smaller  than  the  corre- 
sponding reflex  upon  the  other  side. 

(G)  Paralytic  attacks  or  "spells."  These  may  be  differen- 
tiated as  simple,  epileptiform  and  apoplectiform  attacks.  The 
simple  attacks  are  transitory  spells  of  dizziness  or  faintness,  not 
infrequently  followed  by  a  brief  state  of  confusion,  with  occa- 
sional loss  of  power  of  speech.  The  epileptiform  attacks  usually 
are  of  the  cortical  convulsive  type  (Jacksonian  epilepsy)  :  less 
often  they  are  true  epileptic  seizures.    They  are  usually  fol- 


186     THE  UNSOUND  MIND  AND  THE  LAW 

lowed  by  distinct  impairment  in  the  bodily  and  mental  condi- 
tions. They  differ  from  true  epileptic  convulsions  in  having  an 
accentuated  cortical  character,  progressing  from  one  muscular 
territory  to  another,  and  in  the  long  duration  of  many  of  the 
attacks,  the  slight  impairment  of  consciousness  that  usually  ac- 
companies them,  and  the  focal  symptoms  often  transitorily  pres- 
ent after  the  attack  (hemiplegia,  aphasia,  spasms).  Apoplecti- 
form attacks  are  less  frequent  than  the  other  kinds.  The  patient 
when  thus  afflicted  turns  pale,  suddenly  loses  consciousness  and 
falls  to  the  ground.  Upon  the  return  of  consciousness  focal 
symptoms  are  usually  present,  but  soon  disappear  completely. 
The  transitory  nature  of  all  these  paralyses  is  characteristic 
of  paresis.  Hence,  if  epileptiform  or  apoplectiform  attacks, 
followed  by  paralyses,  which  rapidly  and  completely  disappear, 
occur  in  an  individual  of  middle  age,  they  should  always  arouse 
a  suspicion  of  the  existence  of  a  beginning  paresis.  In  this  dis- 
ease all  the  nervous  symptoms  we  have  mentioned  may  be  pres- 
ent in  various  combinations.  In  general  a  positive  diagnosis 
can  be  made  when  several  of  the  symptoms  are  present  and  are 
associated  with  incipient  mental  weakness.  In  many  cases  of 
paresis,  pronounced  nerve  symptoms  are  altogether  absent  or 
else  manifest  themselves  only  very  late  in  the  course  of  the 
disease.  Then  our  diagnosis  will  have  to  depend  entirely  upon 
a  psychological  analysis  of  the  case.  Every  such  paresis,  even 
when  in  other  ways  it  resembles  a  paranoia,  melancholia  or 
other  psychosis,  will  to  a  greater  or  less  degree  bear  the  follow- 
ing characteristic  symptoms: 

(1)  Disorders  of  intelligence  and  impairment  of  intel- 
lectual powers.  These  manifest  themselves  in  an  enfeeble- 
ment  of  judgment,  in  uncritical  delusions,  in  a  disability  for 
persistent  exertion  and  in  an  erroneous  conception  of  external 
happenings. 

(2)  Disorders  of  memory.  Forgetfulness  is  a  frequent 
symptom  of  paresis.  Impairment  appears  particularly  early  in 
whatever  knowledge  has  been  acquired  by  rote,  such  as  the  mul- 
tiplication table,  dates,  geographical  names,  etc.  Where  a  sus- 
picion of  paresis  exists  the  memory,  on  account  of  the  marked 
diagnostic  significance  of  its  disorders,  must  be  carefully  tested 
according  to  the  methods  indicated  in  a  previous  chapter. 

(3)  Disorders   of   moral   sensibility.     The    patients   become 


PSYCHOSES  IN  GENERAL  187 

indifferent  to  the  requirements  of  proper  conduct,  commit  in- 
discretions and  offenses,  show  carelessness  and  uncleanliness  in 
person  and  dress,  and  not  infrequently  indulge  in  drink  or 
other  excesses. 

Hence,  we  may  repeat  that  whenever  in  persons  of  middle 
age  we  encounter  a  noticeable  change  in  character  marked  more 
especially  by  an  impairment  of  the  intellectual  powers,  by  de- 
fects of  memory  and  moral  weakness,  a  strong  suspicion  of  a 
beginning  paresis  is  warranted  even  if  typical  nerve  symptoms 
such  as  pupilary  rigidity  are  lacking. 

Finally,  it  is  of  importance  for  the  early  diagnosis  of  paresis 
to  remember  that  this  affection  almost  always  begins  slowly  and 
insidiously.  The  initial  stage  in  the  majority  of  instances 
presents  the  same  aspects.  As  a  rule  the  first  indications,  which, 
by  the  way,  do  not  disclose  the  seriousness  of  the  trouble  and 
often  cause  it  to  be  looked  upon  as  a  neurasthenia,  are  very 
vague  symptoms  made  up  of  a  certain  nervous  restlessness, 
irritability,  sleeplessness  and  apprehensive  depression.  Soon 
the  patient  becomes  forgetful,  distraught,  inattentive  and  care- 
less and  is  unable  to  follow  his  occupation  with  his  wonted  pre- 
cision. The  signs  of  mental  weakness  become  more  and  more 
pronounced,  the  transgressions  of  good  breeding  more  and  more 
distinct  and  the  alterations  of  character  more  marked,  until 
finally  we  are  led  to  a  recognition  of  the  actual  trouble  by  an 
unexpected  act  of  violence,  not  infrequently  an  offense  against 
public  decency  or  some  other  contravention  of  the  law,  a  para- 
lytic attack,  the  onset  of  delusions  or  some  other  symptom  of 
insanity.  The  initial  stage  is  followed  by  more  or  less  rapid 
progress  of  the  disease.  Next  to  dementia  praecox,  paresis  is 
the  most  Protean  of  all  psychoses ;  and  for  this  reason  all  other 
psychoses  must  be  passed  in  review  before  a  differential  diag- 
nosis can  be  made.  When  we  find  such  unmistakable  symptoms 
as  pupilary  rigidity  or  absent  knee  jerks,  and  particularly  when 
these  are  supported  by  a  positive  Wassermann  test,  there  can 
be  no  doubt  regarding  the  diagnosis.  But  if  definite  physical 
symptoms  are  lacking,  when  an  apparently  functional  disease 
is  present,  the  diagnosis  becomes  essentially  a  question  of 
psychologic  analysis. 

The  recognition  of  dementia  precox  and  of  paresis  in  their 
early  stages  constitutes  one  of  the  chief  problems  of  psychiatric 


188     THE  UNSOUND  MIND  AND  THE  LAW 

diagnosis,  and  at  the  same  time  one  that  carries  with  it  the 
utmost  significance  from  a  social  and  forensic  point  of  view. 
For  this  reason  these  affections  should  always  stand  in  the  fore- 
ground of  our  deliberations.  Occasionally  paresis  occurs  before 
the  twentieth  year,  and  then  it  is  generally  dependent  upon 
hereditary  syphilis.  Paresis  is  met  with  also  between  the  twen- 
tieth and  thirtieth  year  and  is  then  designated  as  juvenile. 
Aside  from  their  early  occurrences,  these  two  forms  of  the  dis- 
ease present  no  special  feature  differing  from  ordinary  paresis. 
In  accordance  with  the  dominance  of  individual  symptoms, 
paresis  may  be  divided  into  four  distinct  classes,  as  follows: 
the  demented,  the  depressive,  the  expansive  and  the  agitated 
form. 

A.     THE   DEMENTED   FORM   OF   PARESIS 

This  type  is  the  most  common,  and  nearly  one-half  of  all  cases 
of  paresis  follow  their  course  as  a  simple  progressrve  dementing 
process,  devoid  of  all  other  psychic  symptoms  such  as  melan- 
cholia or  manic  phases,  hallucinatory  excitement  or  marked  de- 
lusional manifestations. 

The  initial  stage  is  similar  in  all  forms  of  paresis.  The  pa- 
tients become  restless,  sleepless,  irritable  and  forgetful.  Their 
inability  to  adjust  themselves  to  ordinary  conditions  of  life  be- 
comes more  and  more  manifest,  and  they  soon  become  distraught 
and  inattentive.  The  official  who  previously  was  always  re- 
liable neglects  his  duties  and  behaves  toward  his  superiors  in 
an  unseemly  manner.  Without  noticing  it  themselves,  the  pa- 
tients become  dull  and  apathetic,  lose  their  sense  of  propriety 
and  take  no  interest  in  the  doings  of  the  people  about  them. 
From  time  to  time  slight  and  inadequate  causes  will  produce 
conditions  of  excitement.  Soon  the  alteration  of  character  be- 
comes more  pronounced.  The  patients  neglect  personal  appear- 
ance, make  use  of  indecent  expressions,  associate  with  the  com- 
monest people  and  not  infrequently  commit  deeds  that  bring 
them  into  conflict  with  the  law. 

The  acme  of  the  disease  is  signalized  by  the  presence  of  accen- 
tuated characteristic  symptoms.  The  handwriting  is  paretic, 
the  speech  disordered,  and  tremor,  ataxia,  paralytic  attacks  and 
other  motor  and  sensory  manifestations  make  their  appearance. 


PSYCHOSES  IN  GENERAL  189 

Delusions  also  are  present,  having  more  often  a  paranoid  or 
hypochondriacal  coloration,  but  occasionally  they  are  feeble- 
minded delusions  of  grandeur.  The  memory  shows  distinct  de- 
fects in  every  direction.  Important  occurrences  in  the  previous 
life  of  the  patient,  geographical  and  historical  facts,  and  even 
everyday  occurrences  are  forgotten.  His  store  of  words  is  mani- 
festly reduced,  and  often  abridged  to  a  few  expressions  which 
are  constantly  used  and  repeated.  He  commits  gross  errors  of 
calculation  in  the  most  simple  arithmetical  problems,  his  emo- 
tional tone  is  apathetic  or  depressed,  or  else  is  characterized  by 
a  stupid,  feeble-minded  sense  of  contentment.  Paralytic  at- 
tacks are  of  very  frequent  occurrence  in  the  demented  form 
of  paresis. 

Occasionally  remissions  occur,  during  which  all  the  mental 
symptoms  of  the  disease,  even  the  disorders  of  intelligence,  may 
disappear,  and  one  or  other  of  the  physical  symptoms  may  be 
much  less  pronounced  than  previously.  These  remissions  very 
rarely  last  longer  than  several  months.  Then  the  disease  takes 
on  a  fresh  impetus,  which  leads  to  permanent  dementia.  All 
psychic  life  is  destroyed;  memory,  except  for  a  few  occurrences 
of  early  life,  is  entirely  obliterated.  The  patient  chatters  non- 
sensically, or  else  he  is  more  or  less  stolid  and  leads  an  animal- 
like existence  in  which  the  excretions  are  uncontrolled  and  in- 
voluntarily passed.  Not  infrequently  as  a  result  of  the  physical 
passivity  and  mental  apathy,  bed  sores  are  produced.  Usually 
death  occurs  as  a  result  of  a  paralytic  attack,  an  aspiration 
pneumonia  or  some  other  intercurrent  disease. 

Differential  Diagnosis 

The  demented  form  of  paresis  may  be  confounded  with 
neurasthenia,  with  the  convulsions  of  epilepsy  or  urasmia,  with 
brain  syphilis,  focal  disease  of  the  brain  and  senile  dementia. 

Like  the  paretic,  the  neurasthenic  may  manifest  an  incapacity 
for  concentrated  mental  work,  and  a  marked  tendency  to 
fatigue,  may  be  emotionally  hypersensitive,  hypochondriacal 
and  anxious  and  may  complain  of  dizziness,  head  pressure  and 
tremor.  His  reflexes,  too,  may  be  greatly  increased.  But  the 
neurasthenic  always  has  a  pronounced  feeling  of  illness,  recog- 
nizes that  he  is  sick  and  desires  to  be  cured.    His  hypochon- 


190     THE  UNSOUND  MIND  AND  THE  LAW 

driacal  apprehensions  are  always  preceded  by  actual  disturb- 
ances, although  these  may  be  very  insignificant.  Pupilary  rigid- 
ity and  the  other  typical  paretic  symptoms  are  absent.  Besides, 
the  neurasthenic  patient  shows  no  intellectual  decline  and  no 
defects  of  memory,  and  he  does  not  violate  the  requirements  of 
moral  obligations.  Rest  improves  the  neurasthenic,  but  not  the 
paretic. 

We  have  already  mentioned  how  the  paralytic  attacks  of 
paretics  may  be  differentiated  from  the  convulsions  of  epilep- 
tics. Those  of  uraemia  may  be  distinguished  by  the  accompany- 
ing cedemas,  the  asthmatic  spells  and  the  frequent  presence  of 
singultus  or  vomiting.  Besides,  the  urine  contains  albumin  and 
casts. 

Brain  syphilis  is  often  most  difficult  to  differentiate  from 
paresis.  In  brain  syphilis  we  would  be  likely  to  find  signs  of 
syphilis  in  other  parts  of  the  body,  but  this  is  true  also  of 
paresis.  The  most  reliable  differential  diagnostic  test  will  be 
found  in  the  results  that  may  be  obtained  by  means  of  anti- 
syphilitic  treatment.  It  will  often  produce  prompt  amelioration 
in  brain  syphilis,  but  in  paresis  such  success  has  not  as  yet  been 
obtained,  notwithstanding  the  claims  of  recent  clinicians. 

Focal  diseases  of  the  brain,  more  particularly  of  the  frontal 
lobes,  may  produce  a  clinical  picture  similar  to  that  of  paresis. 
The  general  symptoms  of  brain  tumor  (choked  disc,  etc.),  as 
well  as  the  focal  symptoms  that  are  present,  when  taken  in  con- 
nection with  the  previous  history  of  the  patient's  illness,  will 
usually  lead  to  a  correct  diagnosis. 

The  states  of  pseudo-paresis  that  follow  intoxications  of  alco- 
hol, lead,  carbonic  oxide,  etc.,  differ  from  true  paretic  states  in 
the  amelioration  that  ensues  in  the  bodily  and  mental  symptoms 
when  the  causal  poisoning  has  been  withdrawn  and  eliminated. 
Not  infrequently  paretics  in  the  beginning  of  their  disease  have 
recourse  to  alcoholic  stimulation ;  and  as  a  rule,  because  the  dis- 
ease has  already  made  them  intolerant  to  alcohol,  they  show  the 
intoxication  effects  much  more  strikingly.  Not  infrequently 
delirium  tremens  supervenes.  Only  after  a  long  period  of  ab- 
stinence, when  the  symptoms  of  alcoholic  intoxication  have  dis- 
appeared, can  the  diagnosis  be  made  with  certainty.  Then,  if 
speech  defects,  pupilary  rigidity  and  other  paretic  symptoms 
are  still  demonstrable,  it  is  probable  the  disease  is  present.    In 


PSYCHOSES  IN  GENERAL  191 

pseudo-paresis  due  to  lead  poisoning,  the  presence  of  museulo- 
spiral  and  other  paralyses,  as  well  as  of  peculiar  states  of 
stupor,  together  with  the  general  symptoms  of  lead  poisoning, 
will  aid  us  in  recognizing  the  trouble.  To-day  it  no  longer  holds 
true  that  a  saturnine  encephalopathy  may  be  indistinguishable 
from  paresis,  either  by  its  clinical  picture  or  its  course. 

Senile  dementia,  finally,  may  be  differentiated  from  paresis 
by  the  loss  of  memory  for  recent  events,  while  the  old  memory 
store  remains  clear  and  trustworthy  during  an  astonishingly 
long  period  of  time.  Moreover  the  mildness  of  the  symptoms  of 
nerve  irritation  or  nerve  destruction  and  the  slower  course  of 
the  dementia  will  be  of  diagnostic  aid.  Old  age  and  signs  of 
senile  decay  (presbyopia,  areus  senilis,  arteriosclerosis,  etc.), 
all  point  to  a  senile  dementia,  of  course. 

B.     THE  DEPRESSIVE   FORM   OF   GENERAL  PARESIS 

The  entire  picture  of  this  clinical  type  is  dominated  by  a 
state  of  sorrowful  depression  with  depressive  delusions.  Not 
infrequently  conditions  develop  which  very  much  resemble  a 
melancholia,  especially  when  ideas  of  sinfulness  are  present. 
The  depressive  form  of  paresis  most  often  occurs  at  a  somewhat 
later  age  than  the  other  forms,  usually  setting  in  between  the 
fortieth  and  forty -fifth  year  of  life.  Notwithstanding  its  marked 
resemblance  to  a  true  melancholia,  its  paretic  character  can 
usually  be  recognized  in  the  early  stage  of  its  development. 
The  sorrowful  affect  is  not  so  deep  nor  so  persistent  as  in  true 
melancholia.  Apathy  and  indifference,  notwithstanding  the  ex- 
istence of  depressing  delusions,  dominate  the  entire  situation, 
and  the  patient's  appetite  and  ingestion  of  food  are  usually 
good. 

The  characteristic  sign,  the  mental  weakness,  becomes  more 
and  more  manifest;  expression  is  given  to  absurd  hypochon- 
driac and  paranoid  delusions ;  hallucinations,  especially  of  hear- 
ing, are  not  infrequent.  States  of  fear  in  which  the  patients 
may  attempt  self-destruction  are  transitorily  present.  Often 
the  depression  is  interrupted  by  short  periods  of  euphoria,  dur- 
ing which  isolated  childish  ideas  of  grandeur  are  unfolded.  In 
some  instances  of  the  depressive  form,  the  picture  is  character- 
ized by  the  presence  of  more  or  less  systematized  delusions  of 


192     THE  UNSOUND  MIND  AND  THE  LAW 

grandeur,  in  a  way  resembling  paranoia.  Thought  audition  in 
which  everything  the  patient  thinks  or  speaks  is  announced  or 
repeated  by  the  voices,  and  other  hallucinations,  notions  of  allu- 
sion, delusions  of  inferiority  and  similar  symptoms  occur.  But 
sooner  or  later  there  sets  in  a  progressive  mental  decline,  accom- 
panied by  other  symptoms  of  paresis,  including  paretic  or 
paralytic  attacks. 

Differential  Diagnosis 

From  a  diagnostic  point  of  view  the  main  differential  ques- 
tion will  be  of  a  melancholia  or  a  paranoia.  In  men  melan- 
cholia occurring  before  the  fiftieth  year  is  rare.  Hence,  in  con- 
sidering the  possibility  of  melancholia  we  need  only  do  so  in 
cases  of  women,  in  whom  this  affection  often  begins  around  the 
forty-fifth  year.  In  melancholia  we  meet  with  a  continuous  and 
persisting  deeply  sorrowful  state,  accompanied  by  depressive 
delusions.  The  paretic  is  more  unstable,  often  apathetic,  and 
occasionally  euphoric.  His  delusions  are  most  changeable.  Not 
infrequently  in  the  early  stages  of  paresis  we  encounter  involun- 
tary micturition,  a  symptom  that  is  hardly  ever  present  in 
melancholia.  The  melancholiac  weeps  but  little  or  not  at  all. 
The  paretic  sheds  tears  frequently  and  profusely.  The  adept 
will  be  able  to  draw  differential  diagnostic  conclusions  even 
from  the  facial  expression.  The  physiognomy  of  the  melan- 
choliac is  stolid,  that  of  the  paretic  relaxed  and  undefined. 
Somatic  symptoms  such  as  pupilary  rigidity,  absent  knee  jerks, 
etc.,  will,  of  course,  indicate  paresis.  A  history  of  lues  and  a 
positive  "Wassermann  reaction  will  also  be  obtainable  where 
paresis  is  present. 

So  far  as  the  differential  diagnosis  from  paranoia  is  con- 
cerned, the  paretic  with  paranoid  delusions  may  be  distin- 
guished from  the  true  paranoiac  by  the  slight  influence  that 
the  delusions  exert  upon  his  actions,  by  the  ease  with  which  his 
delusions  may  be  influenced,  and  by  the  inconsistencies  or  by 
the  monotony  or  rapid  changeability  of  his  delusions.  In  the 
paretic,  the  paranoiac  character  is  but  slightly  emphasized.  On 
the  contrary,  the  patients  are  usually  lax  and  without  energy, 
while  true  paranoiacs  defend  their  system  of  delusions  with 
passionate  volubility.    During  the  further  course  of  paresis  the 


PSYCHOSES  IN  GENERAL  193 

increasing    psychic    enfeeblement,    together    with    the    somatic 
symptoms,  will  make  the  diagnosis  clear. 

C.     EXPANSIVE   OR   CLASSIC   FORM    OF   PARESIS 

This  form  of  dementia  paralytica  is  characterized  essentially 
by  the  existence  of  paretic  delusions  of  grandeur.  After  the 
ordinary  initial  symptoms  of  paresis  are  noted  the  patient 
passes  through  a  depressive  stage  which  gradually  reaches  its 
acme,  but  in  exceptional  cases  occurs  suddenly.  In  the  begin- 
ning the  patients  are  usually  only  lightly  maniacal,  but  in  a 
constant  state  of  joyous  exaltation,  talkative,  over-confident  and 
egotistic.  This  state  is  followed  by  one  of  wild  uncontrolled 
activity.  The  patients  travel  to  and  fro,  evolve  countless  plans 
of  which  not  one  is  carried  out,  and  manifest  a  senseless  desire  for 
purchasing  everything  they  see.  Soon  innumerable  and  constantly 
changing  notions  of  grandeur  manifest  themselves.  These  carry 
the  evident  stamp  of  feeble-mindedness,  bear  no  relation  to  one 
another  and  may  be  easily  altered  and  endlessly  elaborated  by 
means  of  suggestive  questioning.  Often  the  grandiose  ideas 
are  accompanied  by  wholly  nonsensical  fantastic  confabula- 
tions. In  his  childishly  joyous  mood  the  paretic,  if  not  promptly 
placed  under  control,  will  quickly  squander  his  entire  fortune. 
Of  frequent  occurrence  also  are  states  of  marked  excitement 
(paretic  mania)  in  which  the  patients  become  furiously  and 
blindly  destructive  and  may  commit  dangerous  acts  of  violence. 
The  grandiose  stage  may  persist  for  months  and  years.  It  is 
particularly  in  this  expansive  form  of  paresis  that  remissions 
occur.  Gradually  as  the  disease  progresses  the  grandiose  ideas 
pale  and  become  more  monotonous.  More  and  more  the  de- 
mentia obtrudes  itself.  Symptoms  of  paralysis  become  notice- 
able ;  the  entire  emotional  life  becomes  dominated  by  a  childish 
stupid  euphoria.  Little  by  little  pronounced  dementia  sets  in; 
yet  all  in  all  the  course  of  the  grandiose  form  of  paresis  is 
longer  than  that  of  the  other  forms.  It  lasts  four  or  five  years, 
and  even  longer. 

Differential  Diagnosis 

From  a  differential  diagnostic  point  of  view  we  should  not 
forget  that  now  and  then  paresis  may  begin  quite  suddenly  un- 


194     THE  UNSOUND  MIND  AND  THE  LAW 

der  the  guise  of  an  acute  mania.  If  no  somatic  symptoms  of 
paresis  can  be  discovered,  a  differential  diagnosis  cannot  be 
made  until  the  further  course  of  the  disease  introduces  the  cor- 
roborative symptoms.  Usually,  however,  even  in  the  absence 
of  all  somatic  symptoms,  the  existence  of  paresis  may  be  in- 
ferred from  the  character  of  the  grandiose  delusions.  The 
mental  weakness  that  usually  places  its  stamp  upon  the  entire 
picture,  the  nonsensical  childish  ideas  of  grandeur,  the  frequent 
hypochondriacal  and  paranoiacal  delusions,  the  emotional  varia- 
tions which  may  suddenly  transform  a  "Crcesus"  into  a  mis- 
erable being  "who  is  rotten  through  and  through,"  the  ease 
with  which  the  delusions  can  be  influenced,  are  all  characteristic 
of  paresis.  If  at  the  same  time  speech  disorder,  paralytic  at- 
tacks and  other  somatic  symptoms  exist,  if  the  previous  history 
is  that  of  a  syphilitic  infection,  or  if  the  Wassermann  reaction 
is  positive,  the  diagnosis  can  no  longer  be  in  doubt. 

Not  infrequently  a  paresis  will  take  its  course  under  the 
guise  of  a  circular  insanity,  and  this  resemblance  will  be  all 
the  more  pronounced  when  accentuated  remissions  take  place. 
But  here  again  the  enfeeblement  of  mental  powers,  the  memory 
defects,  the  immorality,  the  manifest  progress  of  the  disease 
and  the  presence  of  characteristic  physical  signs  will  make  a 
correct  diagnosis  possible. 

D.     THE   AGITATED   FORM   OP   PARESIS 

This  type  represents  an  expansive  form  of  paresis  accom- 
panied by  marked  constant  motor  excitement.  The  patients 
are  in  a  continuous  state  of  unrest,  are  unceasingly  and  pur- 
poselessly busy,  laugh,  sing,  talk  without  interruption,  and 
evolve  the  most  roseate  and  nonsensical  grandiose  ideas.  This 
form  rarely  lasts  more  than  two  years.  In  some  instances  the 
intensity  of  the  excitement  brings  about  rapid  general  ex- 
haustion, which  leads  to  death  in  a  few  weeks  or  months.  The 
agitated  form  of  paresis,  on  account  of  its  rapidly  fatal  course, 
has  also  been  called  galloping  paresis.  From  other  katatonic 
maniacal  states  it  can  be  differentiated  by  the  bodily  and  mental 
symptoms  of  paresis  that  always  accompany  it. 


PSYCHOSES  IN  GENERAL  195 

Forensic  Aspects 

Criminal  charges  against  paretics  are  not  so  frequent  as  civil 
actions  against  them.  This  is  probably  because  in  most  in- 
stances it  is  so  manifest  the  patient  is  suffering  from  a  mental 
disorder  that  he  is  quickly  interned  in  an  institution  for  the 
insane.  The  contraventions  of  criminal  stamp  most  often  com- 
mitted by  paretics  are  exposure  of  person  and  other  offenses 
against  public  decency,  assault  with  attempt  to  kill,  theft,  fraud 
and  incendiarism. 

In  the  estimation  of  criminal  as  well  as  civil  offenses,  great 
difficulty  may  be  caused  by  the  remissions  that  so  often  occur. 
Where  a  punishable  act  has  been  committed  during  such  remis- 
sions and  the  diagnosis  is  clearly  established  from  the  previous 
history  and  from  the  continuing  physical  and  mental  disturb- 
ances, there  should  be  no  difficulty  in  demonstrating  the  true 
state  of  affairs;  but  where  only  physical  symptoms  are  present 
and  all  the  mental  ones  have  passed  away,  it  will  hardly  be 
possible  to  prove  the  patient  is  insane.  In  other  words,  the 
physical  symptoms  of  paresis,  taken  alone,  are  not  sufficient  to 
establish  a  person's  incompetency  or  irresponsibility.  Kemis- 
sions  to  the  extent  of  reestablishment  of  complete  mental  in- 
tegrity are  most  unusual,  however.  As  a  rule  some  disorder 
of  conduct,  some  alteration  in  character,  some  defect  in  memory 
will  be  demonstrable.  In  those  rare  instances  in  which  the 
patient  has  apparently  regained  his  previous  mental  health,  the 
careful  expert  will  defer  giving  a  definite  opinion  for  at  least 
one  year. 

Particularly  when  the  primary  psychic  weakness  is  accom- 
panied by  a  maniacal  exaltation  associated  with  grandiose  ideas 
and  so  slight  that  its  true  significance  is  not  yet  recognizable, 
do  we  encounter  instances  of  senseless  expenditures  and  dis- 
sipation which  may  end  in  indebtedness  of  all  kinds  and  possibly 
financial  ruin.  It  is  such  conditions  that  lead  to  the  execution 
of  promissory  notes,  or  of  wills,  the  bestowal  of  gifts  and  even 
the  making  of  a  promise  to  marry.  Often  enough  we  hear  that 
a  paretic  who  married  a  prostitute  immediately  after  meeting 
her  has  died  within  a  year  or  two  and  left  his  entire  fortune  to 
the  widow.  Because  such  dire  results  are  likely,  it  is  well  in 
most  instances  of  paresis  to  seek  the  appointment  of  a  guardian 


196     THE  UNSOUND  MIND  AND  THE  LAW 

early  in  the  course  of  the  disease.     If  this  rule  were  followed, 
many  a  family  would  be  saved  from  economic  ruin. 


2.    Dementia  Precox 

Just  as  every  psychosis  arising  in  middle  age  should  first  lead 
one  to  think  of  a  paresis,  so  all  psychoses  occurring  between  the 
ages  of  eighteen  and  twenty-eight  should  primarily,  from  a 
practical  standpoint,  raise  suspicion  of  a  dementia  praecox. 
By  the  latter  term  the  newer  school  of  psychiatry  designates  a 
group  of  psychoses  that  bear  these  two  characteristics : 

First,  they  begin  in  youth,  either  during  or  just  after 
puberty. 

Second,  they  involve  a  progressive  mental  decline  which 
mainly  affects  the  emotions  and  the  will  and  to  a  less  extent 
the  thought  processes  and  the  memory,  therefore,  leading  to 
emotional  apathy  and  enfeeblement  or  loss  of  will  power  with  a 
relative  retention  of  sensory  receptivity.  In  some  cases  deep 
dementia  occurs. 

Dementia  praecox  embraces  a  large  part  of  all  the  psychoses 
that  occur  in  youth.  The  clinical  pictures  under  which  it  may 
manifest  itself  are  extraordinarily  diverse.  In  the  beginning 
there  may  be  symptoms  of  a  depressive,  paranoiac  or  katatonic 
state,  and  it  is  only  later  that  their  true  character  of  juvenile 
dementia  becomes  plain.  The  prognosis  of  dementia  praecox  is 
very  bad. 

Despite  the  manifold  aspects  under  which  this  juvenile  de- 
menting process  takes  its  course,  three  main  forms  may  be  dif- 
ferentiated, as  follows:  1,  Dementia  praecox  simplex;  2,  De- 
mentia praecox  paranoides;  3,  Dementia  praecox  katatonica. 

Formerly  these  main  types  of  dementia  praecox  were  desig- 
nated purely  symptomatically  as  mania,  melancholia  or  acute 
paranoia,  or  by  some  other  similar  term.  Even  at  the  present 
time,  after  so  much  has  been  done  by  Kraepelin  and  others  to 
make  possible  the  early  recognition  of  dementia  praecox,  an 
erroneous  diagnosis  of  melancholia  is  most  often  made.  It 
should  be  borne  in  mind  that  juvenile  melancholia  is  a  disease 
not  recognized  by  the  teachings  of  modern  psychiatry.  True 
melancholia  is  a  psychosis  of  advancing  years,  of  the  regres- 
sive period  of  life,  and  is  not  of  frequent  occurrence.    In  youth 


PSYCHOSES  IN  GENERAL  197 

states  of  depression  may  arise  which  bear  certain  characteristics 
of  melancholia,  but  differ  materially  in  their  course.  Moreover 
we  should  remember  that  systematized  paranoia  usually  de- 
velops around  the  beginning  of  the  third  or  the  end  of  the 
second  decade  of  life,  that  paresis  is  rarely  observed  before  the 
thirtieth  year  and  that  true  katatonia  is  usually  a  psychosis  of 
middle  age.  Hence,  where  we  are  dealing  with  a  youthful  pa- 
tient, no  matter  what  symptoms  he  or  she  may  present,  melan- 
cholia may  always  be  excluded,  and  only  occasionally  will  it  be 
worth  while  considering  the  possibility  of  paranoia  or  paresis. 
The  younger  the  patient  the  more  improbable  becomes  the  pos- 
sibility of  a  paranoia  or  paresis.  According  to  Kraepelin  sixty 
per  cent  of  all  cases  of  dementia  prsecox  begin  before  the 
twenty-fifth  year,  the  simple  form  usually  starting  between 
the  fifteenth  and  twenty-fifth  year  of  life,  the  paranoid  form 
beginning  around  the  end  of  the  second  decade  and  one-half 
of  the  katatonic  eases  setting  in  around  the  twenty-fifth  year. 

A.     DEMENTIA  PRECOX  SIMPLEX 

Dementia  Prascox  Simplex,  also  called  hebephrenia,  usually 
begins  insidiously  and  unnoticeably.  Its  further  course  is  that 
of  a  slow  progressive  dementing  process  unaccompanied  by  any 
decided  symptoms,  such  as  severe  excitement,  marked  delusions 
or  katatonic  manifestations.  The  initial  symptoms  are  usually 
vague  and  might  easily  lead  us  to  suppose  the  trouble  is  a 
neurasthenia.  The  patients  complain  of  sleeplessness,  a  feeling 
of  exhaustion,  headache,  inability  to  work  and  of  similar  things. 
Soon,  however,  a  change  in  character  is  noticeable.  The  patients 
become  quiet,  dreamy  and  reserved.  They  lose  interest  in 
mental  pursuits,  become  indifferent  to  their  friends  and  rela- 
tives, and  after  a  while  lead  a  silent,  moody  vegetative  exist- 
ence. Now  and  then  they  give  expression  to  single  depressive  de- 
lusional ideas.  Sense  deceptions  are  rare  and  play  no  role  in  this 
affection.  The  relatives  of  the  patients,  in  fact,  usually  believe 
them  to  be  not  sick,  but  lazy  or  obstinate. 

Sometimes  the  psychosis  begins  with  a  stage  of  sorrowful  de- 
pression. The  patients  are  causelessly  downcast,  bemoan  their 
wasted  lives  and  may  even  attempt  to  kill  themselves.  This 
initial  state  of  depression  rarely  continues  as  an  outstanding 


198     THE  UNSOUND  MIND  AND  THE  LAW 

feature;  on  the  contrary,  it  usually  remains  superficial  and 
variable.  Very  often  the  sorrowful  affect  is  accompanied  by 
hysterical  symptoms,  so  the  inexperienced  observer  is  likely  to 
look  upon  the  trouble  as  one  of  hysteria.  During  the  further 
course  of  dementia  prcecox  simplex,  however,  depression  and 
hysterical  symptoms  fade  more  and  more,  the  sorrowful  affect 
wanes  and  the  emotional  enfeeblement,  the  psychic  dulness  and 
the  inattention  dominate  the  situation. 

Particularly  characteristic  in  the  beginning  of  a  hebephrenia 
is  the  combination  of  depressive  and  paranoid  notions.  The 
patients  are  sorrowful,  but  the  affect  is  not  deep.  They  give 
expression  to  ideas  of  sinfulness,  claim  to  have  lost  all  interest 
in  life  and  want  to  die.  Isolated  hallucinations,  often  indefinite 
in  character,  set  in.  The  patients  suffer  from  persecutory  ideas, 
believe  themselves  to  be  constantly  observed  and  watched  and 
often  think  they  are  being  poisoned.  Notwithstanding  the  ex- 
istence of  such  suspicions  a  paranoid  character  does  not  develop. 
The  patients  speak  of  their  delusions  in  an  unemotional  manner 
and  even  take  their  food  willingly  and  regularly,  despite  their 
depression  and  their  delusions  of  poisoning. 

In  still  other  instances  the  psychosis  sets  in  more  or  less  sud- 
denly under  the  guise  of  a  mild  state  of  excitement.  The  pa- 
tients laugh  inordinately  about  every  trifle.  Some  giggle  and 
laugh  incessantly,  are  in  a  persistently  elated  state,  talk  a  great 
deal,  sing,  rhyme,  make  puns  and  play  all  kinds  of  nonsensical 
practical  jokes.  This  farcical  mood  does  not  last,  but  is  suc- 
ceeded by  a  state  in  which  auditory  hallucinations  of  a  threaten- 
ing and  vituperative  nature  are  present.  The  patients  become 
depressed  and  suspicious,  talk  of  suicide  and  give  expression  to 
delusions  of  a  depressive  or  sexual  paranoid  make-up,  the  ab- 
surdity of  which  reveals  the  existing  feeble-mindedness  usually 
from  the  very  beginning.  In  some  patients  the  delusions  are 
predominantly  religious  in  character.  They  see  glittering  stars, 
spirits  of  the  dead,  celestial  beings,  etc. ;  they  hear  the  voice  of 
God,  believe  themselves  glorified  and  speak  in  an  irrational, 
preachy  manner.  Often  at  a  very  early  period  of  the  trouble 
nonsensical  grandiose  ideas,  not  infrequently  the  direct  result 
of  the  patients'  hallucinations,  set  in.  In  other  instances  iso- 
lated katatonic  symptoms,  mannerisms  in  eating  and  speaking, 
affectations  of  various  kinds  and  a  preference  for  the  use  of  im- 


PSYCHOSES  IN  GENERAL  199 

posing  oratorical  phrases,  accompanied  by  facial  contortions, 
dominate  the  picture.  Very  frequently  in  these  patients  we 
find  silly  laughter,  arising  purely  imperatively  without  any 
recognizable  motive  and  directly  characteristic  of  their  de- 
mented state. 

In  all  forms  of  simple  dementia  prascox,  whether  it  begins  as 
an  almost  symptomless  process,  as  a  simple  depression,  as  a  de- 
pression with  paranoid  notions  or  more  acutely  with  excitement, 
the  further  course  of  the  disease  always  is  marked  by  an  in- 
creasing devastation  in  the  emotional  sphere,  by  apathy,  loss 
of  interest  and  an  enfeeblement  of  the  judgment  and  will. 
Rarely,  however,  is  there  any  pronounced  disturbance  of  orien- 
tation and  reasoning.  Hence,  the  consciousness  remains  un- 
obscured,  even  in  those  cases  which  take  an  acute  and  subacute 
course,  and  in  which  delusions  and  hallucinations  predominate; 
but  orientation  regarding  the  patient's  surroundings  is  often 
disturbed  by  delusional  misinterpretations.  Some  juvenile  de- 
ments will  interpret  their  surroundings  in  a  paranoid  sense, 
believing  themselves  to  be  confined  in  a  prison  and  surrounded 
by  enemies.  At  the  beginning  of  the  psychosis  they  will  realize 
that  they  are  sick  or,  at  least,  that  they  have  a  more  or  less 
marked  feeling  of  illness.  Patients  know  that  their  condition 
is  different  from  what  it  was,  that  their  will  power  is  becoming 
more  and  more  enfeebled,  and  some  of  them  seem  vaguely  to 
comprehend  the  fate  that  awaits  them.  They  complain  their 
heads  are  hollow,  that  their  brains  are  like  sieves,  that  they  are 
going  insane  and  cannot  be  cured.  Later  these  notions  become 
less  frequent  and  when  the  patients  do  speak  of  them  their 
words  are  uttered  in  an  unemotional,  unmeaning  manner. 

The  memory  for  the  distant  past  often  suffers  but  little  or 
not  at  all.  Patients  even  after  years  of  illness  possess  an  aston- 
ishing store  of  knowledge  acquired  in  school  and  are  able  to 
give  a  correct  account  of  the  happenings  of  their  previous  lives, 
even  when  certain  events  are  delusionally  and  weak-mindedly 
misinterpreted.  On  the  other  hand,  the  memory  for  recent 
events  suffers  progressively  from  the  very  beginning  of  the 
psychosis,  this  being  due  above  all  to  the  gradually  increasing 
diminution  of  attentiveness.  The  perceptional  and  appercep- 
tional  power  is  in  general  undisturbed.  As  these  patients  no 
longer  take  interest  in  anything,  and  as  the  emotional  proc- 


200     THE  UNSOUND  MIND  AND  THE  LAW 

esses  that  in  the  main  determine  the  faithfulness  of  memory  lie 
fallow,  all  new  impressions  pass  by  without  arousing  new  feel- 
ings or  creating  new  thought  processes.  The  patients'  power  of 
judgment  in  some  cases  is  manifestly  diminished,  often  very 
early.  This  becomes  more  evident  when  they  are  confronted  by 
unexpected  problems  or  by  an  alteration  in  their  circumstances 
of  life.  Consequently  it  will  be  found  most  difficult  to  train 
juvenile  dements  to  even  the  most  simple  physical  work;  but 
when  so  trained  they  will  be  untiringly  active  in  a  purely  auto- 
matic way.  They  are  not  capable  of  any  independent  bodily  or 
mental  work,  and  are  entirely  unable  to  carry  on  a  connected 
conversation,  even  upon  a  topic  relating  to  occurrences  in  their 
past  lives.  They  are  often  extraordinarily  credulous,  may  be 
made  to  believe  the  greatest  absurdities  and  are  gullible  in  the 
extreme.  Their  stunted  emotional  life  manifests  itself  plainly 
when  they  are  visited  by  friends  or  relatives ;  on  such  occasions 
they  show  little  or  no  interest  in  the  visitors,  but  at  once 
greedily  devour  the  sweets  brought  to  them.  In  a  more  ad- 
vanced stage  of  the  dementia,  eating  and  drinking  constitute  the 
patients'  sole  interest  in  life.  Many  develop  an  actual  voracity 
and  become  fat  and  bloated.  The  final  stage  of  the  disease  is 
marked  by  a  total  lack  of  mental  activity.  The  patients  are 
stolid  and  unconcerned  and  lead  a  purely  vegetative  existence. 
Now  and  then  this  is  interrupted  by  a  short  period  of  silly  ex- 
citement or  by  some  impulsive  outbreak  in  which  they  will  break 
a  window,  hurl  some  object  across  the  room  or  strike  any  person 
within  reach.  Often  they  soil  themselves  by  uncontrolled  evac- 
uations. 

In  the  beginning  of  the  psychosis  their  speech  usually  shows 
no  derangement.  Even  in  the  later  stages  of  the  disease  com- 
plete disconnectedness  of  speech  is  unusual,  but  upon  the  other 
hand  play  upon  words,  silly  remodeling  of  words  and  con- 
struction of  new  ones,  preference  for  high  sounding  and  foreign 
words,  and  stereotyped  repetition  of  the  same  inane  phrases 
are  very  frequently  observed.  The  written  productions  of  these 
patients  correspond  to  their  verbal  ones.  These  writings  are 
often  astonishingly  careless  and  unclean  in  appearance  and  the 
contents  plainly  show  the  condition  of  the  patients'  minds.  The 
handwriting  is  sometimes  katatonically  altered,  disfigured  by 


PSYCHOSES  IN  GENERAL  201 

numerous  extraordinary  flourishes  and  characterized  particu- 
larly by  innumerable  senseless  interlineations. 

The  patients'  posture  is  usually  a  relaxed  one,  with  head  bent 
forward,  the  arms  swinging  loosely  to  and  fro,  the  gait  unelastic 
and  often  dragging;  the  entire  appearance  is  careless,  disor- 
derly and  unclean.  The  facial  expression  bears  the  stamp  of 
dementia.  The  hanging  lower  jaw,  the  half  open  mouth,  from 
which  saliva  dribbles  constantly,  the  absence  of  all  facial  ex- 
pression, the  flattened  naso-labial  folds,  the  immobile  forehead, 
the  frequent  silly  laughter,  all  amply  characterize  the  existing 
trouble. 

The  course  of  the  psychosis  usually  extends  over  a  number  of 
years,  until  a  state  of  profound  dementia  is  reached.  Some- 
times the  dementia  sets  in  very  rapidly,  occurring  after  only  a 
few  months  of  illness.  Most  often  the  end  stage  is  represented 
by  a  state  of  apathy  in  which  the  patients  may  appear  entirely 
idiotic.  In  a  small  percentage  of  cases,  where  the  more  acute 
stage  of  the  psychosis  has  terminated,  the  disease  no  longer 
progresses  and  the  patients'  intellectual  weakness  remains  sta- 
tionary at  a  level  which  still  permits  of  their  employment  in 
various  physical  occupations.  A  small  number  of  hebephrenics 
recover  to  a  certain  degree  after  a  lapse  of  time,  so  they  are 
able  to  return  to  their  former  regular  occupation,  and  some- 
times they  even  seem  to  have  regained  their  previous  health. 
Nevertheless  no  acquirement  other  than  those  which  they  for- 
merly knew  is  ever  possible.  The  so-called  cured  hebephrenics 
usually  fulfil  the  most  unimportant  places  in  the  world's  work. 
In  them  all  ambition  has  been  interred.  Many  succumb  in  the 
struggle  for  existence,  as  the  demands  of  even  normal  daily 
life  represent  to  them  an  excessive  burden  under  which  they 
must  break  down.  After  a  period  of  quiescence,  the  psychosis 
again  flares  up  and  continues  its  work  of  destruction,  turning 
the  patients  into  beggars  and  tramps  and  finally  landing  them 
in  poorhouses  or  state  prisons. 

Differential  Diagnosis 

The  differential  diagnosis  of  dementia  prascox  in  its  initial 
stage  may  involve  some  difficulty.  The  true  character  of  the 
psychosis  is  often  not  recognized  and  a  diagnosis  of  melancholia, 


202     THE  UNSOUND  MIND  AND  THE  LAW 

hysteria  or  neurasthenia  is  made.  Let  us  again  state  that  there 
is  no  such  thing  as  a  melancholia  in  very  young  people;  the 
states  of  depression  that  occur  in  early  life  are  usually  part  of  a 
manic  depressive  psychosis,  of  hysteria,  of  epilepsy,  or  above 
all,  of  a  dementia  prascox.  From  the  point  of  differential  diag- 
nosis we  must,  therefore,  consider  the  following: 

(1)  Hysteria.  Typical  hysterical  symptoms,  contractures, 
paralyses,  anaesthesias,  and  pronounced  hysterical  convulsions 
speak  against  hebephrenia.  The  hysterical  symptoms  occurring 
in  the  latter  psychosis  are  for  the  most  part  imperfectly  de- 
veloped. The  emotional  dulness,  the  inattentiveness  and  the 
lack  of  insight  shown  by  the  juvenile  dement  are  in  strong  con- 
trast to  the  marked  sensitiveness,  the  exalted  emotional  out- 
breaks, the  acuteness  of  observation  and  the  pronounced  ability 
to  attract  attention  by  means  of  simulation  that  characterize  the 
hysteric.  Sense  deceptions  and  delusions  usually  also  speak 
against  hysteria. 

(2)  Epilepsy.  Many  epileptics  suffer  from  frequent  states 
of  depression.  Sense  deceptions,  delusions  and  katatonic  symp- 
toms also  occur,  and  the  dementia  of  some  epileptics  may  be 
considerable  even  in  their  third  decade  of  life.  Nevertheless  it 
should  not  be  difficult  to  differentiate  such  cases  from  hebe- 
phrenia. In  many  instances  the  anamnesis  will  lead  to  a  cor- 
rect diagnosis.  Moreover  the  profound  disturbances  of  con- 
sciousness and  the  various  epileptic  attacks  will  enable  the  true 
nature  of  the  disease  to  be  recognized.  The  dementia  of  epilep- 
tics involves  to  an  equal  extent  the  memory  for  recent  and  for 
far  distant  events,  while  in  hebephrenia  the  knowledge  that  has 
been  acquired  in  school  usually  remains  preserved  to  an  aston- 
ishing degree.  The  physiognomy  and  the  conformation  of  the 
skull  should  also  be  of  diagnostic  aid. 

(3)  Neurasthenia.  The  neurasthenic  recognizes  that  he  is 
sick,  desires  to  recover  and  shows  no  signs  of  mental  enfeeble- 
ment.  All  pronounced  psychic  symptoms,  such  as  delusions, 
states  of  excitement  and  exaltation,  controvert  the  diagnosis  of 
neurasthenia.  Rest  brings  relief  to  the  neurasthenic,  but  not 
to  the  hebephrenic. 

(4)  Manic  Depressive  Insanity.  The  initial  states  of  depres- 
sion of  hebephrenics  may  be  mistaken  for  the  depressive  phases 
of  a  manic  depressive  psychosis.    In  dementia  prascox  simplex, 


PSYCHOSES  IN  GENERAL  203 

however,  the  affect  is  commonly  not  deep  seated  and  the  delu- 
sions usually  present  will  aid  in  arriving  at  a  correct  interpre- 
tation of  the  disease.  Distinct  psychic  motor  inhibition  with 
vivid  fear  occurs  only  in  manic  depressive  insanity.  In  the 
latter  also  the  attentiveness  is  usually  undisturbed.  The  manic 
states  that  occur  in  the  early  period  of  a  hebephrenia  also  may 
be  confounded  with  the  manic  phase  of  a  manic  depressive  psy- 
chosis, but  the  silly,  puerile  stamp  of  the  excitement,  the  affecta- 
tion of  manner,  the  mannerisms  of  speech,  the  sparseness  of 
original  or  humorous  thoughts,  as  well  as  the  delusions  and  emo- 
tional enfeeblement,  will  identify  a  beginning  dementia. 

B.     DEMENTIA   PRECOX   PARANOIDES 

Dementia  precox  paranoides  is  characterized  by  the  prev- 
alence of  hallucination  and  paranoiac  delusions  which  remain 
present  for  a  long  time  or  persist  until  the  condition  becomes 
one  of  accentuated  feeble-mindedness.  In  this  form  of  dementia 
prgecox  the  latter  state  often  supervenes  rapidly.  According  to 
Magnan  the  course  of  the  psychosis  is  as  follows: 

1 — An  initial  stage  or  formative  period.  2 — A  period  of 
persecutory  delusions.  3 — A  period  of  heightened  self-esteem 
(delusions  of  grandeur).  4 — A  period  of  feeble-mindedness 
(dementia). 

Like  all  other  forms  of  dementia  precox,  this  one  usually  be- 
gins with  a  brief  initial  depression.  Then  more  or  less  acutely 
there  develops  a  state  of  apprehensive  excitement  in  which  the 
patients  sigh  or  pray  excessively,  behave  in  a  peculiar  manner, 
commit  isolated  impulsive  acts  of  extraordinary  nature  and  at 
an  astonishingly  early  stage  form  delusions  of  a  predominantly 
paranoiac  character.  The  patients  believe  they  are  being 
watched  and  observed,  think  they  have  been  poisoned,  and  soon 
there  exists  a  fully  developed  persecutory  psychosis,  replete 
with  nonsensical  fantastic  delusions.  The  patients  will  believe 
that  all  they  say  is  being  counteracted  by  means  of  hypnotic 
influence;  that  their  brains  are  being  drained  away  by  me- 
chanical means;  that  their  thoughts  are  being  read  by  some 
magical  process;  that  their  intestines  are  being  removed  and 
rubber  tubing  inserted  in  their  stead;  that  the  world  has  been 
entirely  changed,  the  clocks  are  all  wrong,  everything  is  but 


204     THE  UNSOUND  MIND  AND  THE  LAW 

deceit  and  trickery.  The  delusions  are  accompanied  by  in- 
numerable sense  deceptions,  hallucinations  of  hearing  and  of 
general  sensation  being  particularly  frequent.  Often  the  pa- 
tients hear  their  own  ideas  announced  in  loud  tones.  During 
these  initial  hallucinatory  phases  they  may  show  the  utmost 
excitement.  They  pray  for  mercy,  for  relief,  for  poison  or  for 
a  quiet  death,  show  a  marked  tendency  to  self-destruction  and 
often  commit  dangerous  attacks  upon  others.  In  marked  con- 
trast to  the  existing  delusions  and  vivid  sense  deceptions,  the 
orientation  of  these  patients,  their  power  of  reflection  and  their 
appreciation  of  the  surrounding  world  remain  generally  well 
preserved. 

As  the  psychosis  progresses  the  excitement  dwindles.  Single 
katatonic  symptoms,  mannerisms  of  movement  and  speech, 
slight  negativism  and  traces  of  automatism  become  manifest 
here  and  there  and  ultimately  ideas  of  grandeur  are  noted. 
These  are  usually  of  an  extravagant  adventuresome  nature,  are 
constantly  changing  and  are  of  a  nonsensical  character  closely 
resembling  those  of  paresis.  The  patients  believe  themselves 
to  be  great  warriors,  reformers,  potentates;  they  lived  centuries 
ago  in  the  form  of  characters  renowned  in  history.  With  the 
onset  of  expansive  delusions,  the  state  of  apprehensive  excita- 
tion gives  way  to  a  feeble-minded  euphoria  or  an  exuberant  joy- 
ousness.  The  patients  adorn  themselves  with  fantastic  clothing, 
wear  decorations  and  medals  and  conduct  themselves  in  a 
ridiculous  imposing  manner.  The  paranoiac  delusions  persist 
and  become  intertwined  with  the  notions  of  grandeur.  Hypo- 
chondriacal delusions  are  rarely  wanting  and,  like  all  other  de- 
lusions, bear  an  impress  of  feeble-mindedness  from  their  very 
beginning.  Confabulations  of  the  most  extraordinary  kind  are 
frequent.  Little  by  little  the  characteristic  picture  of  juvenile 
dementia  stands  out  upon  the  paranoiac  background.  The  de- 
lusional edifice  becomes  monotonous  and  unproductive,  the  de- 
lusions themselves  become  indistinct  and  confused,  the  patients 
become  dull  and  an  increasing  erraticism  tends  to  monopolize 
their  psychic  existence.  Outwardly  they  remain  fairly  atten- 
tive and  self-controlled,  answer  simple  questions  correctly  and 
are  oriented  at  least  to  the  extent  that  their  conception  of  the 
surrounding  world  has  remained  uninfluenced  by  delusions  and 
by  a  false  recognition  of  the  persons  about  them. 


PSYCHOSES  IN  GENERAL  205 

The  memory  store  from  previous  times,  especially  the  knowl- 
edge that  has  been  acquired  in  school,  remains  astonishingly 
well  preserved.  Grimacing  and  continuous  demented  laughing 
are  of  frequent  occurrence.  The  speech  of  these  paranoid  ju- 
venile dements  is  confused,  interspersed  with  indistinct  notions 
of  grandeur  and  persecution  and  not  infrequently  characterized 
by  nonsensical  stereotyped  modes  of  expression.  Their  writings 
bear  the  same  stamp  and  are  usually  replete  with  fantastic 
nonsense.  Very  characteristic  are  certain  new  word  construc- 
tions. Some  patients  employ  these  to  such  an  extent  that  they 
constitute  almost  a  special  language.  The  end  stage  of  this  af- 
fection is  a  more  or  less  deep  dementia.  Some  cases  event- 
ually show  a  certain  systematization  of  their  delusions,  so  that 
their  similarity  to  a  paranoia  may  become  very  pronounced.  But 
even  then  the  fantastic  and  nonsensical  guise  of  the  delusions 
and  the  rapid  onset  of  the  feeble-mindedness  show  us  that  we 
must  be  dealing  with  a  juvenile  dementia. 

The  variety  of  the  delusional  edifice  has  led  to  a  further  sub- 
division of  the  paranoid  form  of  dementia  prsecox.  Thus  we 
read  of  a  physical  persecutory  mania,  of  a  mania  of  obsession, 
etc.  Patients  in  the  former  class  are  tortured  by  manifold  sen- 
sations and  hallucinations  in  the  inner  organs  of  the  body,  the 
skin,  and  the  sexual  apparatus,  which  they  interpret  in  the 
most  fantastic  paranoid  manner.  They  maintain  they  are  being 
pricked  with  pins,  tortured  by  means  of  electric  currents,  chlor- 
oformed, rendered  unconscious  and  sexually  abused,  that  their 
intestines  are  being  twisted  and  turned,  their  semen  being 
drawn  off,  etc.  In  the  mania  of  obsession  these  tortures  are 
ascribed  to  demonic  influences.  The  latter  of  course  is  but 
rarely  encountered  in  this  enlightened  twentieth  century.  In 
the  middle  ages  it  played  an  important  role  and  furnished  the 
witch  persecutors  and  their  fire  heaps  with  many  a  sacrifice. 
In  this  mania  of  obsession  or  possession,  the  patients'  enemies 
and  persecutors  are  supposed  to  inhabit  the  human  body  in  the 
form  of  some  evil  spirit  or  in  that  of  the  devil  himself.  In 
the  one  instance  therefore  the  patients  believe  themselves  to  be 
persecuted  by  natural  enemies,  in  the  other  by  extraterrestrial 
ones. 


206     THE  UNSOUND  MIND  AND  THE  LAW 

Differential  Diagnosis 

The  differential  diagnosis  of  the  paranoid  form  of  dementia 
prascox  will  have  to  be  made  from  the  following: 

(1)  Hallucinatory  Confusion.  The  initial  stages  of  paranoid 
dementia  praecox  when  accompanied  by  marked  hallucinatory 
excitement  may  be  remindful  of  an  hallucinatory  confusional 
state.  The  distinction  between  the  two  conditions  should  always 
be  made,  if  possible,  on  account  of  their  totally  different  course. 
In  our  consideration  of  hallucinatory  confusion  we  shall  take  up 
this  question  in  greater  detail. 

(2)  Paranoia.  The  differentiation  between  dementia  prascox 
paranoides  and  paranoia  itself  should  be  made  in  every  case. 
The  reader  is  referred  to  the  chapter  on  Paranoia  for  a  consid- 
eration of  this  question. 

(3)  Dementia  Paralytica.  Inasmuch  as  a  dementia  praecox 
paranoides  usually  does  not  develop  until  toward  the  third  dec- 
ade of  life,  it  may,  when  in  its  expansive  delusional  stage,  be  con- 
founded with  dementia  paralytica.  The  retention  of  the  knowl- 
edge that  has  been  acquired  in  school  and  of  good  arithmetical 
capability  count  against  paresis,  while  the  presence  of  somatic 
symptoms,  such  as  pupilary  rigidity,  speech  disorders,  etc.,  is  an 
evidence  of  the  existence  of  the  latter  disease.  A  history  of 
syphilitic  infection  or  a  positive  Wassermann  serum  reaction  of 
course  also  creates  a  suspicion  of  paresis. 

C.      DEMENTIA  PRECOX  KATATONICA 

While  dementia  prascox  paranoides  is  characterized  by  a 
prevalence  of  hallucinations  and  delusions,  the  importance  of 
these  sense  disturbances  in  dementia  prascox  katatonica  is  as 
small  as  it  is  in  dementia  simplex.  It  is  true  they  may  often  be 
present  in  the  katatonic  form,  but  they  are  always  of  subsidiary 
moment,  occurring  episodically  and  usually  disappearing  com- 
pletely as  the  dementia  increases. 

Dementia  prascox  katatonica  is  a  dementing  process  charac- 
terized by  numerous  katatonic  symptoms.  States  of  excitement 
with  endless  repetition  of  senseless  words,  stereotyped  move- 
ments and  impulsive  bizarre  acts,  alternating  with  manifest 
stupor,   mutism  and  muscular  tension,   negativism  alternating 


PSYCHOSES  IN  GENERAL  207 

with   an   abnormal   augmented   suggestibility — these   constitute 
the   chief   characteristics   of  this   prognostically   hopeless   psy- 
chosis. Its  occurrence  is  less  frequent  in  men  than  in  women,  and 
in  the  latter  it  sets  in  most  often  during  the  puerperium.    Usu- 
ally it  commences  in  very  much  the  same  manner  as  dementia 
prascox  simplex.     Vague  nervous  symptoms  appear  first,  then 
sense  deceptions  and  delusions  of  all  kind,  particularly  of  a 
religious    nature,    with    occasional    katatonic    symptoms    inter- 
spersed.    The  latter  consist  of  stereotyped  postures  and  move- 
ments, abnormally  prolonged  innervations  of  the  muscles  of  the 
face,  tension  of  the  body  muscles  and  nonsensical  remarks  of  the 
most   extraordinary  nature.     These    all   are   among  the   early 
symptoms  of  the  disease ;  but  in  a  short  time  the  katatonic  symp- 
toms become  more  and  more  numerous  and  phases  of  true  kata- 
tonic excitement  alternate  with  states  of  stupor.     Then  the  pic- 
ture of  the  disease  is  fully  developed.     In  a  small  proportion 
of  cases  the  katatonic  symptoms  set  in  without  any  preliminaries. 
When  the  katatonic  form  of  dementia  preecox  is  at  its  height, 
its  manifestations  are  of  the  most  varied  kind.     Some  patients 
present  a  symptom  complex  of  katatonic  stupor,  arising  sud- 
denly or  very  gradually  from  the  preceding  state  of  excitement. 
When  it  develops  gradually  the  patients  become  more  and  more 
taciturn ;  at  first  their  words  become  almost  inaudible,  then  they 
merely  move  their  lips  and  utter  no  sound,  and  finally  they 
sink  into  a  state  of  complete  mutism.     Other  manifestations  of 
negativism  usually  make  their  appearance  coincidently  with  the 
mutism.     The  patients  refuse  nourishment,  remove  their  cloth- 
ing, crawl  under  the  bed  or  insist  upon  occupying  the  beds  of 
others  and  oppose  every  attempt  to  induce  them  to  alter  their 
actions.    At  the  height  of  the  stupor  the  muscles  of  the  body  are 
in  a  state  of  persistent  tension  or  else  passive  movement  of  a 
limb  causes  the  antagonists  of  the  muscles  acted  upon  to  con- 
tract. 

The  lips  are  often  considerably  protruded,  the  physiognomy 
empty  and  masklike,  all  play  of  features  extinct  and  sometimes 
a  stereotyped  or  entirely  irregular  mimicry  is  observable. 
Fingers  and  thumbs  are  usually  clinched  or  else  show  the  most 
extraordinary  postural  contrasts.  The  patients  are  entirely  re- 
actionless,  soil  themselves  with  urine  and  feces  and  must  be 
fed.     Deep  pricks  with  a  needle  bring  forth  no  manifestation 


208     THE  UNSOUND  MIND  AND  THE  LAW 

of  pain.  The  eyes  are  sometimes  closed  and  sometimes  wide 
open  with  very  infrequent  blinking  of  the  lids.  It  is  at  this 
phase  of  the  psychosis  that  we  may  observe  those  bizarre  theat- 
rical postures  which  are  so  characteristic  of  the  katatonic  pa- 
tient and  which  often  persist  for  months  or  even  years.  At 
times  sudden  impulsive  acts  unexpectedly  interrupt  the  stupor. 
In  some  of  the  patients  a  state  of  katatonic  excitement  is  main- 
tained for  a  long  period  of  time.  This  usually  sets  in  quite 
abruptly  in  the  course  of  a  deep  stupor  and  is  characterized  by 
stereotyped  manifestations,  by  impulsive  nonsensical  actions,  by 
signs  of  negativism  and  mannerisms  and  by  an  excited  speech 
made  up  of  persistent  repetition  of  senseless  words  and  in  many 
ways  analogous  to  that  encountered  in  flight  of  ideas. 

The  patients  dance  and  jump  about,  often  repeating  the  same 
bizarre  theatrical  movements  again  and  again ;  or  else  they  rock 
themselves  rhythmically  to  and  fro,  assume  theatrical  postures 
and  destroy  their  clothing,  the  bed  clothes  or  anything  that 
comes  within  reach,  oppose  every  attempt  to  keep  them  clean, 
constantly  repeat  the  same  often  senseless  phrases  in  a  monot- 
onous affected  manner,  soil  themselves  with  feces,  wash  them- 
selves with  their  urine,  suddenly  attack  the  doctor,  the  nurse  or 
bystander  in  order  to  pull  his  hair  or  tear  his  clothing,  or  over- 
throw the  furniture,  smash  the  dishes  or  strip  the  pictures  from 
the  wall.  Frequently  marked  sexual  excitement  that  finds  an 
outlet  in  shameless  masturbation  or  obscene  phrases  is  also 
present. 

In  some  cases  the  excitement  bears  the  stamp  more  of  a  pathetic 
ecstasy.  The  patients  are  in  a  constant  state  of  pose,  gesticulate 
in  a  theatrical  manner  and  give  vent  to  a  katatonic  rhetoric  that 
is  characterized  by  high-sounding  words,  consonant  phrases, 
new  formations  and  transformations  of  words,  nonsensical 
rhymings  and  persistent  repetition  of  the  same  utterances. 
Sometimes  the  most  ridiculous  trivialities  are  put  forth  with  a 
pronounced  emphasis  and  gesticulation. 

In  certain  instances  the  excitement  may  be  similar  to  that 
of  maniacal  exaltation ;  but  the  similarity  is  superficial  for,  com- 
bined with  the  joyous  mood  and  the  intensified  motor  and  verbal 
excitement  of  the  maniacal  patient,  we  here  clearly  note  a  fool- 
ish underlying  tone,  mannerisms  and  stereotypy,  a  preference 
for  word  distortions  and  other  mannerisms  of  speech. 


PSYCHOSES  IN  GENERAL  209 

The  course  of  the  psychosis  is  almost  always  a  changeable  one, 
states  of  katatonic  excitement  alternating  with  states  of  de- 
pression; yet  the  sequence  of  the  individual  phases  follows  no 
definite  rule.  Manic  states  of  the  most  irregular  kind  accom- 
panied by  katatonic  gesticulations  and  rhetorical  outbursts  may 
be  followed  by  causeless  depression  and  negativism;  wild  ex- 
citement with  nonsensical  acts  may  be  succeeded  by  shameless 
masturbation  and  the  use  of  vile  language;  deep  stupor  with 
muscular  rigidity  or  flexibilitas  cerea  may  be  followed  by  a 
mild  state  of  excitement  with  rhythmical  verbigerations ;  a  phase 
of  pathetic  ecstasy  by  completely  disconnected  declamations  or 
by  a  short  remission  with  apparent  mental  lucidity. 

Eemissions  lasting  for  hours,  days  or  even  weeks  constitute 
a  noticeable  and  characteristic  symptom.  Patients  who  have 
lain  in  a  state  of  stupor,  or  who  have  been  jumping  about  in  a 
katatonic  disorderly  manner,  suddenly  become  orderly,  give 
correct  answers  and  often  show  marked  insight  into  their  own 
condition.  Usually,  in  such  cases,  however,  a  recurrence  takes 
place  quite  as  rapidly  and  abruptly,  and  in  the  course  of  a  year 
to  a  year  and  a  half  dementia  sets  in.  The  patients  become  more 
and  more  stupid,  the  picture  of  disease  more  monotonous  and 
definite  katatonic  symptoms  permanently  fixed.  In  one  patient 
mild  excitement  with  constant  repetition  of  the  same  phrases 
will  predominate,  in  another  stereotyped  movements  recur  un- 
endingly, in  still  another  complete  absence  of  reaction  gives 
its  stamp  to  the  condition.  Many  patients  sink  into  a  state  of 
deep  dementia,  interrupted  occasionally  by  dangerous  violent 
outbreaks  of  excitement.  In  others  katatonic  mannerisms  fixate 
themselves  in  certain  definite  ways,  so  that  the  patients  attract 
attention  by  their  manner  of  walking,  eating,  saluting,  etc.  Even 
after  the  lapse  of  many  years  these  katatonic  mannerisms  will 
at  a  glance  reveal  the  original  character  of  the  psychosis  which 
meanwhile  has  made  the  transition  to  a  deep  dementia. 

In  still  other  patients  there  develops  a  clownish  feeble-minded 
behavior.  Such  patients,  as  a  result  of  their  great  suggestibil- 
ity, manifest  an  enormously  exaggerated  tendency  toward  mim- 
icry. In  many  katatonics  this  imitative  impulse  attains  such 
a  height  that  everything  done  or  said  in  their  presence  is  copied 
or  repeated.  If,  for  instance,  the  examiner  places  his  left  hand 
upon  his  hip  or  the  palm  of  his  hand  upon  his  head  or  cuts  a 


210     THE  UNSOUND  MIND  AND  THE  LAW 

grimace  the  patient  will  repeat  the  movement  with  the  accuracy 
of  an  automaton.  Some  katatonics  will  follow  an  attendant 
about  the  grounds  for  hours,  stepping  in  each  footmark  he  has 
made,  standing  still  when  he  stops,  sitting  down  when  he  seats 
himself,  and,  in  short,  repeating  all  his  movements  with  utmost 
precision.  In  so  doing,  they  often  caricature  grotesquely  the 
manners  of  their  model,  even  attempting  to  copy  his  mode  of 
speech. 

The  diagnosis  of  dementia  prascox  katatonica  is  based  simi- 
larly upon  the  characteristic  symptoms  of  juvenile  dementia — 
that  is,  emotional  enfeeblement  and  loss  of  will  power  with  a 
relative  preservation  of  consciousness  and  orientation — and 
upon  the  katatonic  signs  present.  In  many  cases  the  patient's 
writings  will  serve  to  establish  the  diagnosis.  These  are  charac- 
terized by  the  same  peculiarities  that  give  their  impress  to  the 
katatonic  manner  of  speech,  a  tendency  toward  the  employment 
of  high-sounding  phrases,  a  constant  repetition  of  the  same 
words,  a  senseless  alignment  of  letters,  words  and  sentences, 
underscores,  new  word  formations,  bizarre  flourishes,  fantastic 
drawings,  etc. 

Differential  Diagnosis 

The  differential  diagnosis  must  be  made  from  the  following: 
(1)  Mania.  The  manic  states  of  excitement  encountered  in 
dementia  praecox  katatonica  may  be  confounded  with  true 
mania.  An  attempt  to  converse  with  the  patient  will  ordinarily 
clear  up  any  doubt  that  may  exist.  The  maniac  may  easily  be 
made  to  keep  to  a  certain  topic  of  conversation,  and  gives  cor- 
rect, pertinent  answers  which  he  usually  elaborates  in  a  flighty 
way;  he  may  also  be  easily  diverted  from  the  subject.  The 
katatonic  patient,  on  the  other  hand,  is  negativistic ;  he  either 
does  not  reply  at  all  or  else  gives  irrelevant  answers.  His  at- 
tention can  be  concentrated  only  with  difficulty  and  his  interest 
cannot  be  held.  The  flight  of  ideas  of  the  maniac  cannot  be 
confounded  with  the  senseless  vaporings  of  the  katatonic.  The 
expressional  movements  of  the  maniac,  while  abnormally  viva- 
cious, are  natural  and  understandable,  inasmuch  as  they  accord 
with  the  predominant  emotional  tone.  On  the  other  hand  the 
expressional  movements  of  the  katatonic   are   exaggerated,  bi- 


PSYCHOSES  IN  GENERAL  211 

zarre,  and  are  not  related  or  bear  an  inverse  relationship  to  the 
ruling  affects.  Thus,  for  instance  a  katatonic  while  uttering 
hypochondriacal  plaints  and  expressing  delusions  of  the  most 
painful  nature  will  smirk  and  smile  without  cessation. 

(2)  Dementia  Paralytica.  Katatonic  symptoms  are  not  in- 
frequently observable  in  paresis,  but  in  this  disease  are  usually 
isolated  ones  and  do  not  bear  the  extraordinary  diverse  and 
manneristic  character  of  the  katatonic.  Moreover,  they  usually 
occur  in  paresis  only  after  the  process  has  already  made  con- 
siderable progress  and  the  presence  of  physical  symptoms  such 
as  pupilary  rigidity,  etc.,  leaves  no  doubt  as  to  the  proper  diag- 
nosis. 

(3)  Hysteria.  In  many  katatonics,  especially  in  the  very 
early  stage  of  the  psychosis,  hysteroid  symptoms,  hysterical  con- 
vulsions, etc.,  may  occur.  The  presence  of  characteristic  traits 
of  juvenile  dementia,  however,  will  assure  us  we  are  not  dealing 
with  a  hysteria. 

(4)  Epilepsy.  During  the  twilight  states  of  epileptics,  cata- 
lepsy, stereotyped  movements  and  verbigerations  are  not  infre- 
quently encountered.  The  profound  disturbances  of  conscious- 
ness, the  difficulty  of  comprehension,  the  apprehensive  confused 
or  ecstatic  facial  expression,  the  marked  monotony  of  the  auto- 
matic movements,  which  usually  do  not  bear  the  impress  of  in- 
congruity and  artificiality,  and  the  blind  acts  of  violence,  will 
differentiate  the  epileptic  patient  from  the  katatonic. 

(5)  Katatonia.  See  the  description  of  katatonia  in  the  fol- 
lowing section. 

Forensic  Aspects 

The  number  of  offenses  against  law  and  order  that  may  be  the 
product  of  precocious  dementing  processes  must  be  evident  from 
a  perusal  of  the  foregoing  matter.  The  unrecognized  inade- 
quacies of  such  individuals  lead  to  constant  troubles  in  every 
position  of  life  requiring  an  appreciation  of  order,  punctuality 
and  discipline. 

As  Huebner  very  appropriately  says,  "If  we  would  appre- 
ciate the  aid  and  protection  that  sufferers  from  dementia  prgecox 
require,  we  must  observe  them  not  only  in  institutions  but  in 
every-day  outside  life,  and  note  how  aimlessly  they  go  about, 


212     THE  UNSOUND  MIND  AND  THE  LAW 

disorderly  clad,  annoying  people  and  authorities,  following  no 
productive  occupation,  making  purposeless  purchases,  attract- 
ing attention  by  their  conduct,  having  differences  with  others, 
and  occasionally  even  being  dangerous  to  their  surroundings." 
In  addition,  however,  the  confusion  and  excited  states  may 
lead  to  all  kinds  of  silly  and  senseless  acts,  as  well  as  to  danger- 
ous ones.  Homicide,  highway  robbery,  theft,  defalcation,  fraud 
and  sexual  offenses  are  among  the  acts  commonly  encountered. 
Often  in  katatonics  it  is  a  question  of  impulsive  acts  committed 
without  any  forethought  or  apparent  motive,  but  the  offenses 
are  premeditated  and  well-considered. 

D.    Katatonia 

Katatonia  is  preeminently  a  psychosis  of  early  age.  About 
three-quarters  of  all  cases  begin  before  the  thirtieth  year  and 
the  majority  terminate  in  feeble-mindedness  or  dementia.  No 
sharp  dividing  line  can  be  drawn  in  this  regard  between  kata- 
tonia and  dementia  praecox  katatonica.  Both  psychoses  differ 
so  little  in  their  clinical  manifestations  that  it  is  hardly  possible, 
when  a  marked  katatonic  symptom  complex  is  present,  to  deter- 
mine whether  the  patient  is  afflicted  with  dementia  praecox 
katatonica  or  with  katatonia.  As  a  matter  of  fact,  Kraepelin 
looks  upon  katatonia  as  a  form  of  the  juvenile  dementing  proc- 
ess and  hence  classifies  it  among  the  precocious  dementias. 

Nevertheless  it  is  necessary,  following  Kahlbaum,  to  dissoci- 
ate certain  cases  of  katatonia  from  the  katatonic  form  of  de- 
mentia praecox  described  in  the  preceding  chapter  and  to  class- 
ify them  in  a  special  category.  These  cases  of  katatonia  are 
characterized  by  their  totally  different  course.  Whereas  the 
prognosis  of  dementia  praecox  is  always  bad,  a  considerable 
number  of  Kahlbaum 's  katatonia  cases  end  in  complete  recovery. 
Hence  it  is  essentially  the  course  of  the  psychosis  and  the  re- 
sult reached  that  enable  us  to  tell  the  difference  between  de- 
mentia praecox  katatonica  and  katatonia. 

According  to  Kahlbaum,  katatonia  is  a  disease  of  variable 
course,  in  which  the  psychic  symptoms  present  a  serial  picture 
of  melancholia,  mania,  stupor,  confusion  and  finally  dementia. 
One  or  other  of  these  symptoms,  however,  may  fail  to  set  in. 
Associated  with  the  psychic  symptoms,  manifestations  on  the 


PSYCHOSES  IN  GENERAL  213 

part  of  the  motor  nervous  system  bearing  the  general  character 
of  spasms  are  observable. 

In  true  katatonia  we  encounter  all  the  symptoms  that  have 
been  described  as  occurring  in  dementia  prsecox  katatonica — 
in  the  beginning  depression  with  notions  of  sinfulness,  followed 
by  hysterical  symptoms,  especially  hysteroid  spasms,  by  con- 
fused delusions  of  a  hypochondriacal  paranoid  and  expansive 
nature,  by  phases  of  peculiar  religious  ecstasy  and  katatonic 
maniacal  excitement  with  pathetic  gesticulations,  verbigerations 
and  speech  mannerisms,  with  imitative  impulses,  flexibilitas  cerea, 
and  a  tendency  to  impulsive  acts  of  violence.  The  duration  of 
the  affection  is  rarely  more  than  one  year.  Nearly  all  kata- 
tonic cases  that  last  more  than  one  year  end  in  dementia,  and 
when  they  do  they  should  be  classed  as  dementia  prsecox  kata- 
tonica. Very  few  cases  recover  after  the  lapse  of  one  year. 
On  account  of  this  uncertainty  of  outcome,  no  definite  prognosis 
should  be  given  in  katatonic  states  until  at  least  a  year  has 
elapsed. 

It  is  precisely  in  this  katatonic  process  of  disease  that  we 
encounter  conditions  which  ultimately  make  for  recovery  not- 
withstanding that  they  bear  the  guise  of  profound  dementia. 
Katatonies  who  are  completely  stupid  and  expressionless,  who 
vegetate  in  a  continuous  stupor  and  who  pass  feces  and  urine 
without  control,  are  probably  demented,  but  after  all  it  is  pos- 
sible that  they  are  not.  Whether  they  belong  in  the  class  of 
dementia  prascox  katatonica  or  in  that  of  Kahlbaum's  kata- 
tonia, can  be  determined  only  by  the  course  and  outcome  of 
the  psychosis,  as  we  have  already  said.  While,  therefore,  a 
delimitation  cannot  be  made  before  dementia  has  definitely  set 
in,  we  can  with  a  fair  amount  of  certainty  assume  that  almost  all 
katatonic  psychoses  that  develop  in  women  during  the  puerperal 
state  present  an  unfavorable  prognosis,  and  therefore  should 
be  classed  as  cases  of  dementia  prsecox  katatonica. 

3.    Acute  Hallucinatory   Confusion 

Acute  states  of  hallucinatory  confusion  often  occur  upon  an 
epileptic  basis  or  in  infectious  diseases.  Delirium  tremens  may  be 
looked  upon  as  an  hallucinatory  confusion  upon  an  alcoholic 
basis.     In  a  restricted  sense,  however,  only  those  cases  are  to 


214     THE  UNSOUND  MIND  AND  THE  LAW 

be  classed  as  hallucinatory  confusion  in  which  epilepsy  and  al- 
cohol or  other  intoxication  may  be  excluded.  This  includes 
those  cases  that  have  been  designated  as  exhaustion  delirium  and 
those  in  which  the  symptoms  are  more  pronounced  in  character, 
as  delirium  acutum.  It  is  advisable,  however,  to  designate 
these  states  according  to  the  psychic  symptom  complex  they 
present,  inasmuch  as  exhaustion  plays  an  etiological  role  only  in 
some  of  the  cases.  True  hallucinatory  insanity,  in  this  restricted 
sense,  is  a  psychosis  of  infrequent  occurrence.  It  is  inaugu- 
rated by  a  sharp  initial  stage.  The  patients  become  restless, 
sleepless  and  apprehensive,  show  marked  emotional  changeabil- 
ity, laugh  and  cry  simultaneously  and  become  confused.  All 
the  symptoms  are  rapidly  augmented  until  the  acme,  charac- 
terized by  the  following  chief  symptoms,  is  reached: 

(1)  Complete  or  Marked  Confusion  Exists.  The  facial  ex- 
pression of  itself  leads  us  to  recognize  the  existence  of  some 
serious  stuporous  state.  The  eyes  are  lusterless  and,  though 
they  manifest  an  occasional  gleam  of  interest,  they  waver  un- 
steadily like  those  of  an  intoxicated  person.  The  face  is  sunken, 
sometimes  pale,  sometimes  congested,  sometimes  apprehensively 
distorted;  occasionally  traversed  by  an  expression  of  tortured 
fatigue,  or  again  by  an  expression  of  complete  indecision.  The 
patients  are  in  a  dream-like  state  and  their  attention  can  be 
riveted  only  with  difficulty.  They  do  not  know  where  they  are, 
answer  the  simplest  questions  incorrectly  and  frequently  mis- 
construe their  surroundings  in  the  most  incredible  way.  They 
observe  what  is  taking  place  about  them  but  all  sensory  impres- 
sions are  incompletely  and  falsely  assimilated.  They  are  no 
longer  able  to  think  clearly;  everything  appears  to  them  enig- 
matical and  incomprehensible.  They  are  unable  to  understand 
even  the  most  simple  occurrences  and  some  of  them  complain 
that  everything  seems  peculiar,  false  and  changed.  The  entire 
state  is  a  kind  of  drunkenness  or  stupor,  with  disorientation, 
confusion  and  difficulty  of  comprehension. 

(2)  The  confusion  is  accompanied  and  augmented  by  in- 
numerable sense  deceptions,  particularly  by  delusions  of  hear- 
ing and  sight.  At  one  time  the  patients  hear  themselves  being 
scolded  and  threatened,  at  another  they  have  visions  of  heaven 
and  the  angels  welcoming  their  arrival.  They  see  wild  animals, 
mystical  birds,  horrible  spirits,  demons,  etc. 


PSYCHOSES  IN  GENERAL  215 

(3)  In  consequence  of  these  sense  deceptions  there  arise  nu- 
merous confusional  unrelated  delusions  that  follow  rapidly  one 
upon  the  other  and  constitute  a  variegated  mixture  of  para- 
noid and  depressive,  or  occasionally  of  hypochondriac  and  ex- 
pansive ideas.  The  patients  usually  talk  in  a  disconnected, 
flighty  and  barely  comprehensible  manner;  they  scream,  laugh, 
scold,  weep,  and  manifest  their  chaotic  delusions  by  a  volu- 
minous outpouring  of  words. 

(4)  The  disease  receives  its  impress  from  the  presence  of  a 
marked  motor  excitement  best  designated  as  psycho-motor  con- 
fusion. The  patients  are  in  a  constant  state  of  unrest,  throw 
themselves  from  one  side  to  another,  remove  their  clothes,  jump 
about,  try  to  run  away,  strike  and  bite,  and  exhibit  an  unceas- 
ing flow  of  purposeless  convulsive  movements. 

(5)  Generally  the  psychosis  becomes  complicated  by  a  series 
of  bodily  disturbances.  The  pulse  is  accelerated,  the  tempera- 
ture rises,  the  tongue  becomes  dry  and  coated,  the  lips  and 
angles  of  the  mouth  are  covered  with  an  inspissated  dirty  saliva 
and  not  infrequently  albuminuria  is  present.  Often  urine  and 
feces  are  passed  involuntarily.  The  severe  cases  of  acute  hal- 
lucinatory confusion  are  designated  as  delirium  acutum  and 
usually  end  fatally  within  a  few  days.  They  are  accompanied 
by  high  fever,  usually  of  more  than  104°  F.,  and  by  symptoms 
of  increasing  exhaustion  and  irritation  which  are  remindful  of 
meningitis.  Among  the  latter  are  persistent  contraction  of  the 
pupils,  strabismus,  muscular  twitchings,  and  a  lolling,  stut- 
tering speech.  Other  cases  terminate  in  recovery,  all  the  symp- 
toms gradually  passing  away  during  the  course  of  three  to  four 
weeks,  or  in  exceptional  instances,  in  the  form  of  a  crisis. 

Differential  Diagnosis 

The  differential  diagnosis  must  be  made  from  the  following: 
(1)  The  Delirium  of  Fever  and  Infections.  These  states 
rarely  last  longer  than  one  week  and  disappear  as  soon  as  the 
fever  has  passed  away.  During  the  course  of  the  deliriums  free 
intervals  often  take  place;  they  occur  particularly  with  remis- 
sion of  the  fever.  Delusions  are  infrequent  and  scattered,  at- 
tacks of  psycho-motor  confusion  usually  slight  and  not  of  long 
duration.    The  diagnosis  of  the  existing  infectious  disease  (scar- 


216     THE  UNSOUND  MIND  AND  THE  LAW 

let  fever,  pneumonia,  articular  rheumatism,  typhoid,  etc.)  deter- 
mine the  diagnosis  of  the  psychosis. 

(2)  Alcoholic  Intoxication.  Delirium  tremens  is  a  psychosis 
so  well  characterized  that  its  differentiation  from  hallucinatory 
confusion  can  hardly  ever  cause  any  difficulty. 

(3)  Epilepsy.  The  differential  diagnosis  between  epileptic 
twilight  states,  perhaps  accompanied  by  albuminuria  and  fever, 
and  hallucinatory  confusion  may  be  difficult  or  even  impossible. 
Sudden  impulsive  acts,  monotone  movements,  the  absence  of 
physical  signs  of  exhaustion,  the  changeable  depth  of  the  clouded 
consciousness  and  the  absence  of  psycho-motor  confusion  speak 
for  epilepsy.     The  anamnesis  is  of  course  important. 

(4)  Dementia  Prsecox  Paranoides.  Frequently  the  states 
of  apprehensive  excitement  that  are  present  in  the  beginning 
of  a  dementia  prsecox  paranoides  are  confounded  with  hallu- 
cinatory confusion.  Aside  from  the  fact  that  the  former  is  a 
chronic  psychosis,  usually  rapidly  leading  to  dementia,  while  the 
latter  presents  a  very  favorable  prognosis,  the  following  points 
will  serve  as  characteristic  marks  of  differentiation :  In  dementia 
prsecox  paranoides,  notwithstanding  the  mass  of  sense  decep- 
tions and  delusions,  there  is  present  in  the  initial  stage  a  high 
degree  of  orientation,  while  on  the  contrary  in  acute  hallucina- 
tory confusion  a  marked  clouding  of  consciousness  and  entire 
disorientation  exist.  Furthermore,  the  former  is  characterized 
by  the  existence  of  purposeful  movements,  while  in  the  latter 
the  motor  impulses  are  ungoverned  and  undirected.  Finally, 
the  conduct  of  the  paranoid  sufferer  is  comparatively  orderly, 
while  that  of  the  hallucinant  is  characterized  by  confusion  and 
exhaustion. 

(5)  Mania.  Maniacal  exaltation,  when  the  motor  and  ver- 
bal excitement  is  at  its  height,  may  bear  great  similarity  to  hal- 
lucinatory confusion.  In  mania,  however,  hallucinations  are 
infrequent  and  are  isolated  occurrences,  the  patient's  compre- 
hension of  his  surroundings  is  but  slightly  disturbed,  the  motor 
unrest  is  orderly  and  controlled  in  comparison  to  the  inordinate 
motor  agitation  of  the  patient  suffering  from  hallucinatory  con- 
fusion. True  flights  of  ideas,  of  course,  speak  for  mania.  In 
the  latter  disease  the  emotional  tone  also  is  usually  a  more 
equable  one  and  differs  from  the  constant  change  of  emotions 


PSYCHOSES  IN  GENERAL  217 

met  with  in  hallucinatory  confusion.    Besides,  the  physiognomic 
expression  of  the  maniacal  patient  is  beaming  and  ecstatic. 

(6)  Katatonia.  Katatonic  excitement  as  a  rule  can  he 
differentiated  usually  from  halluoinatory  confusion,  in  which 
katatonic  symptoms  but  rarely  occur.  The  deeply  clouded  con- 
sciousness, the  disorientation  and  the  signs  of  physical  exhaus- 
tion in  hallucinatory  confusion  are  in  marked  contrast  to  the 
astonishing  collectedness  and  orientation  of  the  katatonic. 

4.    Hallucinatory  Insanity 

Delusions  arising  essentially  from  hallucinations  are  observed 
in  many  psychoses,  particularly  in  acute  alcoholic  insanity, 
cocaine  intoxication,  epilepsy,  and  not  infrequently  in  dementia 
paralytica.  Even  in  paranoia,  intercurrent  hallucinatory  ex- 
citement may  cause  the  production  of  new  delusions.  AIL  these 
instances  having  been  eliminated,  there  still  remains  a  small 
number  of  psychoses  which  must  be  looked  upon  as  a  special, 
although  uncommon  state  of  disease. 

"Hallucinatory  insanity,"  therefore,  is  a  purely  symptomatic 
designation,  just  as  is  the  term  "hallucinatory  confusion."  The 
dominant  character  of  hallucinatory  insanity  is  a  delusional 
structure  depending  solely  upon  sense  deceptions  and  which 
breaks  down  at  once  when  the  sense  deceptions  cease.  If  ever, 
in  psychiatry,  we  are  warranted  in  speaking  of  primary  and 
secondary  disorders,  we  may  do  so  in  true  hallucinatory  insan- 
ity. Here  the  illusions  and  hallucinations  always  constitute  the 
primary  disorder,  and  all  other  disturbances,  particularly  the 
delusions,  are  secondary. 

The  disease  occurs  most  frequently  in  women  during  the 
climacteric.  Its  commencement  is  acute  or  subacute  and  is 
usually  inaugurated  by  a  causeless  sorrowful  depression,  by 
ideas  of  sinfulness,  and  a  tendency  to  suicide — in  short,  by  a 
state  of  depression  that  may  be  remindful  of  melancholia.  The 
patient  is  in  a  state  of  more  or  less  vague  fear;  soon  innumer- 
able hallucinations,  predominantly  of  sight  and  hearing,  set  in. 
Threats,  vituperative  accusations  are  heard ;  the  patients  see 
flames,  apparitions,  ghosts  and  devils.  All  sense  deceptions 
seem  to  be  signalized  by  an  appearance  of  actuality  and  by  ex- 
traordinary plasticity. 


218     THE  UNSOUND  MIND  AND  THE  LAW 

The  sense  deceptions  constitute  the  starting  point  for  the  de- 
lusions. These  are  essentially  depressive,  paranoiacal  and  ex- 
pansive, or,  more  rarely,  hypochondriacal  in  character.  The 
patients  believe  the  end  of  the  world  has  come,  death  and  de- 
struction fill  the  land,  all  their  relatives  have  been  killed.  They 
give  expression  to  ideas  of  persecution,  see  the  gallows  or  the 
electric  chair  upon  which  they  are  to  be  executed,  believe  them- 
selves to  have  been  poisoned,  etc. ;  then  again  ideas  of  gran- 
deur set  in — they  believe  themselves  called  to  the  highest  places 
of  honor,  believe  themselves  to  be  rulers,  queens  or  kings.  All 
these  delusions  occur  in  variegated  alternation  and  are  never 
systematized.  The  patients  will  always  admit  having  heard 
these  things.  The  sense  deceptions  from  which  the  delusions 
arise  are  therefore  quite  as  unconnected  and  changeable  as  the 
delusions  themselves.  The  same  changeable  quality  is  evident 
in  the  emotional  tone.  Usually  it  is  slightly  depressive,  but 
transitorily  it  is  exalted  with  a  religious  coloring.  The  further 
course,  notwithstanding  the  presence  of  alarming  hallucina- 
tions, is  often  characterized  by  a  noticeable  apathy.  No  dis- 
turbance of  consciousness  of  a  more  pronounced  kind  is  pres- 
ent. The  patients  are  usually  clear  or  merely  temporarily  con- 
fused. They  always  remain  oriented  except  when  their  orienta- 
tion has  become  affected  by  pronounced  sense  deceptions.  Their 
orientation  in  regard  to  time  is  never  lost. 

The  course  of  the  psychosis  is  broken  by  remissions  during 
which  the  sense  deceptions,  and  consequently  also  the  delusions, 
disappear,  and  mental  clearness  with  complete  orientation  exists ; 
at  such  times  the  patients  are  perfectly  able  to  analyze  their 
own  delusions.  Even  during  the  ascendancy  of  the  hallucina- 
tions the  patients  frequently  have  complete  insight  into  their 
condition.  We  are  then  able  to  gather  from  their  talk  that  they 
are  aware  of  the  falsity  of  their  beliefs  and  would  like  to  alter 
them.  Sometimes  the  attitude  of  these  patients  regarding  their 
sense  deceptions  is  that  of  a  peculiar  state  of  indecision;  they 
are  in  constant  doubt,  beg  to  be  enlightened  and  demand  to  be 
told  the  truth.  The  entire  picture  of  hallucinatory  insanity  is 
therefore  one  so  characteristic  that  difficulty  in  diagnosis  should 
rarely  arise.  The  duration  of  the  psychosis  is  generally  mea- 
sured by  weeks  or  months.  In  most  instances  the  prognosis  is 
good.    Nevertheless  the  formation  of  fantastic  delusions  may  per- 


PSYCHOSES  IN  GENERAL  2i9 

sist  and  increase,  but  the  hallucinatory  origin  of  these  false  be- 
liefs can  always  be  demonstrated. 

Differential  Diagnosis 

The  differential  diagnosis  is  to  be  made  from  the  following. 

(1)  Alcoholic  Insanity.  The  acute  hallucinosis  of  alcohol- 
ics differs  from  hallucinatory  insanity  by  the  predominance  of 
paranoid  delusions,  by  the  partially  typical  sense  deceptions,  by 
the  pronounced  fear  and  by  the  marks  of  alcoholic  intoxication. 

(2)  Cocainism.  Acute  cocainism  can  be  differentiated 
from  hallucinatory  insanity  by  the  predominant  development 
of  paranoid  delusions,  by  the  presence  of  typical  sense  decep- 
tions (visions  of  very  small  animals  and  sensory  perversions), 
and  by  the  absence  of  remissions.  An  anamnesis  that  indicates 
a  poisoning  by  cocain  or  by  cocain  and  morphin  combined  ren- 
ders the  diagnosis  certain. 

(3)  Paranoia.  Hallucinatory  insanity  may  be  differentiated 
from  paranoia  by  the  absence  of  the  paranoid  character  and  by 
the  variegated  changeability  of  the  delusions. 

(4)  Melancholia.  The  affect  in  hallucinatory  insanity  is 
never  so  stable  nor  so  deeply  depressive  as  it  is  in  melancholia. 
Moreover  in  the  former  all  psycho-motor  and  intellectual  inhi- 
bition is  lacking  and  manifold  delusions  are  present,  whereas 
in  melancholia  depressive  delusions  are  persistently  predom- 
inant. 

(5)  Epilepsy.  The  states  of  hallucinatory  insanity  that 
exist  upon  an  epileptic  basis  differ  from  true  hallucinatory  insan- 
ity by  their  intensely  violent  character,  by  marked  apprehensive 
excitement,  by  impulsive  acts  and  by  more  or  less  pronounced 
obscuration  of  consciousness. 

(6)  Dementia  Paralytica.  Hallucinatory  insanity  occurring 
during  the  course  of  a  dementia  paralytica  may  be  recognized 
by  the  bodily  symptoms  of  paresis  or  by  the  defects  of  intel- 
ligence, memory  or  moral  sense. 

5.    Paranoia 

There  is  one  form  of  mental  disease  which  distinctly  differs 
from  all  other  psychic  disturbances  in  that  the  psychic  per- 
sonality stands  under  the  ban  of  a  plainly  marked  system  of 


220     THE  UNSOUND  MIND  AND  THE  LAW 

delusions  while  the  formal  apparatus  of  thought  remains  intact 
and  primary  emotional  disturbances  are  absent.  This  disease 
is  designated  as  paranoia.  An  explanation  of  the  nature  of 
this  affection  was  formerly  sought  in  the  assumption  that  the 
disease  represented  a  second  stage  of  a  melancholia  or  mania 
of  which  the  emotional  characteristics  had  passed  away  but 
which,  not  being  cured,  must  inevitably  lead  to  dementia. 

The  primary  character  of  this  disease  was  first  recognized 
by  French  psychopathologists,  and  Esquirol  chose  for  it  the 
name  Monomania.  To-day  there  is  no  longer  any  question  that 
the  disease  constitutes  a  special  primary  form  of  psychic  dis- 
order, nor  is  there  any  difference  of  opinion  regarding  the  symp- 
tom complex  it  presents.  Of  the  symptoms,  the  system  of  de- 
lusions is  the  most  marked.  The  fundamental  principle  of  the 
paranoiac 's  delusions  is  that  he  exaggerates  the  notion  of  the 
ego,  displacing  his  own  person  from  its  proper  objective  rela- 
tion to  the  outer  world.  His  own  person  appears  to  him  as  the 
center  of  attention  in  his  surroundings.  Moreover,  he  finds  a 
special  cause  for  this  attention  in  the  imaginary  special  quali- 
ties or  in  the  imaginary  special  social  or  other  significance  of 
his  own  person,  and  as  a  result  this  attention  becomes  a  source 
of  annoyance  or  satisfaction  to  him.  Coincidently  this  atten- 
tion may  also  serve  a  special  purpose,  namely,  that  of  tending 
to  restrict  or  to  promote  him  or  his  own  interests.  Similarly, 
in  his  opinion,  it  may  be  the  endeavor  of  his  surroundings  to 
achieve  this  special  purpose  by  means  of  pertinent  acts.  This 
exaggeration  of  the  ego  differs  in  intensity  in  different  cases  of 
paranoia,  or  in  the  same  case  at  different  times  or  under  dif- 
fering circumstances;  it  may  be  boundless  or  may  keep  within 
certain  limits,  the  latter  to  such  an  extent  that  to  the  super- 
ficial observer  the  confines  of  health  may  seem  not  to  have  been 
overstepped ;  often  it  expresses  itself  in  a  few  precise  directions, 
often  in  many  general  ones.  Always,  however,  and  even  when 
the  delusions  exist  in  but  limited  intensity  and  extent,  the  psy- 
chic personality  as  such  is  diseased.  The  psyche  is  an  indi- 
visible entity,  and  nothing  could  be  more  false  than  to  conclude 
from  the  fact  that  the  disease  manifests  itself  only  in  certain 
special  directions  that  only  a  certain  part  of  the  psychic  per- 
sonality is  diseased.  It  is  also  self-evident  that  the  circle  of 
persons  whom  the  patient  brings  into  relation  with  himself  may 


PSYCHOSES  IN  GENERAL  221 

be  extremely  restricted  or  infinitely  extended  and  may  include 
persons  who  are  entire  strangers  or  even  entirely  imaginary. 

Hence  to  a  certain  extent  it  becomes  manifest  that  in  para- 
noia we  are  dealing  with  a  system atization  of  delusions.  "With 
the  ego  as  the  point  upon  which  the  attention  and  the  conduct 
of  the  surrounding  people  and  things  are  concentrated,  a  prin- 
ciple is  established  which  is  capable  of  logical  elaboration ;  and, 
as  a  matter  of  fact,  it  is  upon  this  basis  that  the  patient  builds 
and  extends  his  delusional  structure.  The  conditions  and  things 
that  objectively  controvert  his  delusions  signify  nothing  to  him, 
for  he  either  ignores  them  or  transmutes  them  so  they  exist  not 
as  an  obstacle  but  rather  as  an  encouragement  to  his  views. 
The  predominance  of  his  ego  is,  so  to  say,  the  supreme  article  of 
faith  to  which  everything  else  must  become  subservient.  This 
transmutation,  falsification  in  many  instances,  extends  also  to 
the  happenings,  to  the  experiences  of  the  delusion-free  past — 
in  other  words,  former  experiences  become  so  falsified  that  they 
can  be  made  to  serve  as  a  foundation  for  actual  delusions. 

A  further  point  of  vantage  for  the  systematization  lies  in  the 
circumstance  that  the  attention  or  the  comportment  of  the 
people  about  him  act  upon  the  paranoiac  either  depressingly 
and  inhibitorily,  or  exaltingly  and  encouragingly.  Whatsoever 
enters  his  delusional  sphere,  no  matter  how  indifferent  it  may 
be,  becomes  transmuted  into  an  inhibitory  or  an  encouraging 
factor.  This  is  the  cause  for  a  sharp  typical  dualization  of  the 
disease,  namely,  into  paranoia  with  the  notion  of  restrained 
interests,  and  paranoia  with  the  notion  of  promoted  interests. 
That  the  delusions  may  become  strictly  systematized  is  possible 
only  because  the  formal  thought  mechanism  of  the  paranoiac 
remains  intact.  In  formal  judgment  and  conclusions  he  does 
not  differ  from  a  person  in  health,  but  this  does  not  hold  true 
as  to  the  premises  for  judgment  and  conclusions.  It  is  only 
these  premises  that  are  established  and  affected  by  his  delusions ; 
the  manner  of  their  elaboration  accords  with  the  formal  laws 
of  logic. 

"While  it  is  true,  as  stated,  that  there  is  an  absence  of  any 
primary  disordered  affect  in  paranoia,  it  is  self-evident  that 
affects  as  such  occur  in  this  disease,  for  the  paranoiac  may  be 
depressed,  exuberant  or  angry  just  like  a  well  person  who  re- 
acts naturally  to  concepts,  whether  correct  or  false. 


222     THE  UNSOUND  MIND  AND  THE  LAW 

The  chronic  progressive  delusional  edifice  with  its  correspond- 
ing alteration  of  character  must  be  looked  upon,  however,  as 
the  psychological  nucleus  of  paranoia,  while  all  other  symptoms 
are  of  comparatively  minor  significance.  Paranoia  in  this 
classic  restricted  sense  is  not  of  frequent  occurrence.  It  is  a  psy- 
chosis that  develops  between  the  twenty-fifth  and  thirty-fifth 
year  of  life,  most  frequently  around  the  twenty-eighth  year. 
The  commencement  of  the  disease  is  usually  vaguely  defined  and 
is  characterized  by  the  occurrence  of  all  kinds  of  indistinct 
complaints,  often  of  a  neurasthenic  nature;  the  patients  be- 
come depressed  without  cause,  give  voice  to  self-accusations,  to 
ideas  of  sinfulness  and  manifest  a  desire  to  end  their  lives. 
These  symptoms,  remindful  of  a  melancholia,  soon  become  com- 
plicated by  others  which  enable  us,  often  very  early,  to  diagnos- 
ticate the  presence  of  a  hopeless  paranoiacal  process.  The  pa- 
tients become  timid  and  suspicious,  withdraw  from  their  friends 
and  relatives  and  express  all  kinds  of  vague  fears.  Soon  the  al- 
teration of  character  becomes  more  pronounced.  Ideas  of  de- 
preciation set  in,  the  patients  believing  themselves  to  be  un- 
justly treated,  neglected  and  slighted.  They  become  quiet,  un- 
responsive, egoistic  and  distrustful.  The  onset  of  isolated  au- 
ditory hallucinations  encourages  the  formation  of  delusions. 
The  words  and  conversations  of  the  people  about  them  seem  to 
the  patients  to  contain  taunts  and  jeers,  vilifications  and 
threats.  Then  the  existing  delusion  of  depreciation  has  been 
augmented  by  that  of  reference.  The  most  harmless  words  and 
gestures  seem  to  the  patient  to  contain  insinuations  and  insults ; 
every  cough,  every  sneeze,  every  expectoration  takes  place  on 
his  account.  The  transition  from  this  state  to  that  of  actual 
delusion  of  persecution  is  established  by  the  delusion  that  he 
is  being  observed.  Day  and  night  he  is  given  no  rest,  every- 
where he  is  followed  by  spies  who  are  controlling  all  his  words 
and  acts.  The  patient  now  becomes  more  and  more  irritable, 
more  curt  and  taciturn,  is  driven  to  and  fro  by  a  constant  state, 
of  unrest  and  manifests — often  toward  his  nearest  relatives 
— a  threatening,  inimical  demeanor. 

The  stage  of  initial  depression  is  followed  by  one  of  out- 
standing persecutory  delusion  and  by  the  development  of  a 
typical  paranoiac  character.  The  idea  that  he  is  being  perse- 
cuted gives  the  patient  a  logical  explanation  for  the  sharp  ob- 


PSYCHOSES  IN  GENERAL  223 

servation  to  which  he  is  supposedly  subjected  or  for  the  general 
attention  he  believes  he  is  receiving.  He  is  being  derided,  de- 
nounced or  slandered  and  everything  is  done  to  make  his  life  un- 
endurable. Wherever  he  appears  all  kinds  of  disagreeable  in- 
sinuations are  made,  and  every  occurrence  refers  to  him;  the 
children  on  the  street  point  accusing  fingers  at  him,  dishonoring 
remarks  are  made  about  him  in  the  theater,  in  the  newspapers 
and  in  church;  everywhere  he  is  surrounded  by  enemies  who 
lay  in  wait  for  him  and  spy  upon  him.  It  is  clear  he  is  the  vic- 
tim of  a  conspiracy.  His  food  he  takes  only  after  he  has  care- 
fully tested  it,  for  he  fears  an  attempt  is  being  made  to  poison 
him. 

Little  by  little  the  delusion  of  persecution  takes  a  more  defi- 
nite form;  there  becomes  established  an  unshakable  delusional 
system  which  completely  transforms  the  patient's  personality 
and  alienates  his  view  of  life  from  that  of  his  companions;  his 
deeper  and  inner  life  becomes  dominated  by  his  delusions  and 
he  is  occupied  solely  with  his  own  self  and  his  pathological  ideas. 
His  own  personality  becomes  the  center  around  which  all  his 
thoughts  revolve.  So  long  as  the  delusion  of  persecution  is  not 
complicated  by  ideas  of  grandeur,  every  thought  refers  to  the 
inimical  relations  the  surrounding  world  bears  to  the  patient's 
own  body.  Every  part  of  his  body  may  in  turn  become  the 
object  for  attack  by  these  inimical  influences.  His  thoughts 
are  being  drawn  from  him,  he  is  being  benumbed  by  electric  or 
magnetic  currents,  his  food  is  being  contaminated  or  poisoned, 
etc.  His  enemies  give  him  no  peace,  his  life,  his  honor,  his 
position  are  constantly  being  endangered;  he  is  a  lonesome 
man,  an  exceptional  man,  against  whom  the  rest  of  the  human 
race  has  conspired,  and  for  this  reason  he  must  be  alert  and 
watchful  in  order  to  protect  himself. 

All  these  delusions  become  reinforced  by  hallucinations,  which, 
however,  are  sparse  and  of  subsidiary  import.  Most  typical  is 
the  association  of  hallucinations  of  hearing  with  hallucinations 
of  body  sensation.  Hallucinations  of  smell  and  taste  also  occur, 
however,  and  nearly  all  of  these  have  a  paranoiac  impress. 
Especially  characteristic  is  the  patient's  delusion  of  hearing  his 
own  thoughts  expressed.  Not  infrequently  the  paranoiac  de- 
lusion is  directed  against  the  conjugal  partner  and  manifests 
itself  in  the  form  of  jealousy.    The  patient  accuses  his  marital 


224    THE  UNSOUND  MIND  AND  THE  LAW 

associate  of  infidelity,  believes  he  perceives  his  rival  in  or  under 
the  bed  and  no  longer  acknowledges  his  children  as  his  own. 
The  number  of  persecutory  ideas  that  may  be  encountered  in 
such  patients  is  legion.  Almost  every  paranoiac  has  his  own 
special  system  of  delusions  which  he  elaborates  in  a  more  or  less 
intelligent  and  fantastic  manner.  From  the  moment  he  believes 
he  has  discovered  the  source  of  his  persecution,  he  becomes  a 
public  menace.  While  he  previously  may  have  been  satisfied 
with  complaints  to  the  authorities  regarding  his  supposed  griev- 
ances and  with  requests  for  legal  protection,  he  now  is  likely 
to  take  matters  into  his  own  hands.  The  persecuted  man  be- 
comes transformed  into  a  persecutor.  Public  abuse,  bodily  in- 
jury, homicidal  attacks  and  homicides  are  among  the  delicts 
that  paranoiacs  commit  during  the  stage  of  persecutory  de- 
lusions, and  it  is  this  fact  that  stamps  the  patients  as  most  dan- 
gerous members  of  society.  Often  the  existing  trouble  is  not 
recognized  until  some  such  overt  act  has  been  committed.  For 
that  reason  the  early  diagnosis  of  the  trouble  and  the  intern- 
ment of  the  patient  in  an  institution  before  the  delusion  of  per- 
secution reaches  so  dangerous  a  stage  are  most  important. 

After  the  psychosis  has  existed  for  a  long  time,  usually  only 
after  a  period  of  years,  the  expansive  delusions  that  signalize 
the  third  stage  of  the  disease  set  in.  These  generally  lead  no 
further  than  to  an  exaggerated  self-esteem,  particularly  in  pa- 
tients whose  intelligence  has  been  of  a  high  order  and  has  re- 
mained more  or  less  unaffected  during  the  progress  of  the  psy- 
chosis. Highly  characteristic  of  such  patients  is  a  pronounced 
tendency  to  inventiveness.  They  often  busy  themselves  with  all 
kinds  of  problems  in  mechanics  and  other  sciences,  and  not  in- 
frequently create  astonishment  by  the  remarkable  originality  of 
their  constructions.  Often,  however,  they  develop  a  pronounced 
delusion  of  grandeur  and  this  usually  proclaims  the  onset  of 
mental  enfeeblement.  Most  paranoiacs  of  this  kind  are  easily 
recognizable  by  their  theatrical  demeanor,  by  their  condescend- 
ing, disdainful  facial  expression,  by  their  imposing  gestures 
and  by  their  love  for  decorations  and  medals.  Apparently  the 
notions  of  grandeur  of  the  later  periods  of  paranoia  do  not 
appear  until  after  the  abatement  and  disappearance  of  the 
numerous  annoying  sensations  to  which  the  paranoiac  is  subject 
during  the  stage  of  persecutory  delusions.     The  grandiose  de- 


PSYCHOSES  IN  GENERAL  225 

lusions,  like  the  persecutory  ones,  are  systematized  and  in- 
fluence the  patients'  emotions  and  actions.  Often  the  ideas  of 
grandeur  are  intimately  bound  up  with  ideas  of  persecution. 
The  patients  believe  themselves  to  be  most  important  person- 
ages; they  control  the  rising  and  the  setting  of  the  sun,  of  the 
stars  and  of  the  moon ;  they  possess  divine  power  and  by  a  mo- 
tion of  the  hand  can  annihilate  thousands.  Thus  they  pass  their 
time  in  a  state  of  radiant  bliss  looking  down  with  contempt  upon 
the  rest  of  miserable  humanity. 

Certain  varieties  of  paranoia  must  be  especially  mentioned. 
Of  particular  interest  in  this  work  is  the  litigious  form.  This 
usually  originates  in  consequence  of  the  loss  of  some  lawsuit. 
The  patient  firmly  believes  his  side  of  the  case  to  have  been 
the  right  one;  he  becomes  entirely  inaccessible  to  all  argument, 
and  it  is  impossible  to  convince  him  of  his  error;  notwithstand- 
ing the  most  careful  explanations  and  demonstrations  his  views 
remain  fixed  and  unalterable.  The  delusional  character  of  his 
belief  that  he  has  been  unjustly  treated  by  the  law  and  by  the 
court  is  shown  by  its  incorrigibility.  Soon  this  idea  dominates 
the  patient's  entire  life.  He  becomes  unalterably  convinced  that 
the  judges  have  been  bribed;  he  suspects  the  lawyers  and  wit- 
nesses of  having  conspired  against  him  and  he  is  likely  to  carry 
the  fight  for  his  supposed  rights  through  all  the  courts.  Often 
the  correct  diagnosis  is  not  made  until  the  litigant  has  sacrificed 
his  fortune,  has  reduced  his  family  to  poverty  and  has  failed 
repeatedly  in  his  senseless  legal  contests. 

There  is  an  extraordinary  resemblance  in  action  among  all 
such  litigants.  Some  of  them  study  the  statute  books  so  care- 
fully that  they  are  able  to  cite  entire  pages,  word  for  word ;  their 
memory  as  a  rule  is  astonishingly  acute  for  everything  con- 
nected with  their  delusions  and  they  are  able  to  argue  dexter- 
ously and  logically.  Nearly  all  of  them  show  the  same  typical 
discursiveness  and  prolixity  in  writing,  and  they  all  have  a 
special,  peculiar  style  which  gives  their  numerous  writings  a 
characteristic  impress.  In  consequence  of  their  insulting  man- 
ner toward  judges,  lawyers  and  witnesses,  in  consequence  of 
their  threats  and  their  open  resistance  to  orders  they  consider 
unjust,  they  are  in  constant  new  conflicts  with  the  law.  The 
disease  usually  runs  into  a  marked  degree  of  intellectual  weak- 
ness. 


226    THE  UNSOUND  MIND  AND  -THE  LAW 

Another  form  of  paranoia  is  that  characterized  by  a  begin- 
ning of  the  delusion  in  early  childhood,  and  in  which  there  is  a 
preponderance  of  the  idea  that  the  patient  is  not  the  child  of 
his  own  parents  but  is  of  noble  birth.  It  is  in  the  light  of  this 
belief  that  he  henceforth  views  his  entire  life.  Patients  thus 
afflicted  regularly  maintain  that  since  childhood  they  have  been 
treated  in  a  remarkable  manner,  either  on  account  of  envy  or 
malevolence.  Such  statements,  made  later  in  life,  may  be  de- 
pendent upon  subsequent  confabulations. 

The  special  forensic  interest  of  the  cases  just  described  must 
be  sought  in  the  fact  that  they  lead  directly  and  essentially  to 
conflict  with  public  officials  and  with  the  courts.  In  every  es- 
timation of  such  cases  stress  must  be  laid  upon  the  character- 
istics that  differentiate  a  mentally  healthy  litigant  from  an  in- 
sane one,  for  it  is  entirely  unwarranted  to  conclude  that  a  per- 
son is  abnormal  merely  because  he  defends  his  rights  in  a  stub- 
born and  impracticable  way.  Nor  does  the  factor  of  morbid 
litigation  suffice  to  characterize  a  case  as  one  of  paranoia,  for 
this  symptom  is  also  found  in  other  forms  of  mental  disorder. 

In  some  paranoiacs  the  delusion  of  grandeur  has  a  domi- 
nating erotic  character ;  they  believe  people  in  high  position  and 
standing  to  be  in  love  with  them  and  that  these  people,  on  ac- 
count of  their  social  position,  are  unable  to  give  expression  to 
their  affection.  Such  paranoiacs  often  persecute  their  supposed 
affinities  with  insistent  verbal  and  written  declarations  of  love. 
In  these  circumstances  also  temporary  notions  of  persecution 
may  set  in  and  as  a  result  the  otherwise  harmless  patient  be- 
comes capable  of  any  act  of  violence. 

In  still  other  paranoiacs  the  delusions  are  more  of  a  religious 
nature.  They  believe  themselves  to  be  chosen  emissaries  of 
God,  great  reformers,  etc.  Such  notions,  though  causing  a  feel- 
ing of  sovereign  power,  will  naturally  be  productive  of  a  mental 
arrogance  of  the  most  extravagant  nature.  Inasmuch  as  such 
delusional  personalities  are  exempt  from  all  control  on  the  part 
of  their  inferior  comrades,  they  may,  particularly  under  the  in- 
fluence of  hallucinations  and  occasional  persecutory  ideas,  com- 
mit the  most  horrible  infractions  of  law  and  propriety.  All  such 
paranoiacs  are  noticeable  on  account  of  their  eccentricities  of 
dress. 


PSYCHOSES  IN  GENERAL  227 

Forensic  Aspects 

It  must  by  now  be  apparent  that  the  forensic  relations  of 
paranoiacs  are  most  extended  and  that  criminal  offenses,  par- 
ticularly, are  common  among  them.  Forcible  entry  into  the 
dwellings  of  other  people,  particularly  into  those  of  public  of- 
ficials or  well  known  personages,  for  the  purpose  of  revenge  or 
protective  appeal,  are  of  frequent  occurrence,  and  letters  of 
denunciation,  threats,  or  accusations,  at  times  couched  in  the 
most  obscene  language,  just  as  often  give  rise  to  legal  compli- 
cations. Physical  injury  to  others  and  even  homicide  are  not 
infrequent,  and  these  are  the  direct  result  of  the  patients'  de- 
lusions of  persecution.  Having  attempted  to  help  themselves 
by  seclusion,  by  changing  their  place  of  residence,  by  moving 
from  house  to  house,  by  fruitless  appeals  to  authorities  they 
finally  take  the  law  into  their  own  hands  and  attack  their  sup- 
posed persecutors.  When  such  things  happen  the  chief  danger 
for  the  persons  attacked  lies  in  their  absolute  ignorance  of  the 
fact  that  they  are  looked  upon  as  the  cause  of  the  paranoiac 's 
troubles.  On  the  other  hand,  the  paranoiac  is  just  as  likely  to 
inflict  severe  physical  injury  upon  himself  in  order  to  direct 
public  attention  to  the  wrongs  that  have  been  done  him  or  the 
cause  which  he  represents.  In  all  instances  in  which  the  exist- 
ence of  a  delusional  system  can  be  shown,  there  can  be  no 
difficulty  in  correctly  judging  the  individual  case,  but  where 
conflicts  with  the  law  occur  while  the  affection  is  still  in  a  for- 
mative stage,  proof  of  irresponsibility  may  be  most  difficult. 

Differential  Diagnosis 

The  differential  diagnosis  of  paranoia  must  be  made  from  the 
following : 

(1)  Dementia  Praecox  Paranoides.  In  contrast  to  para- 
noia, the  paranoid  form  of  dementia  praecox  is  characterized  by 
the  rapid  onset  of  a  more  or  less  marked  dementia,  by  the  pres- 
ence of  abundant  hallucinations,  by  the  comparatively  early  oc- 
currence of  grandiose  ideas,  by  the  confusions  and  absence  or 
meagerness  of  systematization  of  the  delusions,  by  an  augment- 
ing impairment  of  efficiency,  and  by  the  extinction  of  all  emo- 
tions.    The  true  paranoiac  maintains  his  mental  acumen  for 


228    THE  UNSOUND  MIND  AND  THE  LAW 

years,  argues  and  disputes  with  energy  and  intensity,  fights  for 
his  freedom  and  believes  his  confinement  in  an  institution  to  be 
a  grievous  wrong,  while  under  similar  conditions  the  paranoid 
dement  is  usually  quite  at  ease.  In  the  latter  there  generally 
exists  a  pronounced  suggestibility  for  fresh  delusions,  while  the 
delusional  structure  of  the  true  paranoiac  cannot  be  shaken  or 
influenced. 

(2)  Dementia  Paralytica.  Not  infrequently  the  initial  stage 
of  paresis  may  be  paranoid  in  appearance.  If  typical  paretic 
symptoms,  such  as  pupilary  rigidity,  absence  of  knee  jerks  or 
speech  disorders  are  discoverable,  the  diagnosis  can  no  longer  be 
in  doubt.  But  if  the  somatic  symptoms  are  lacking  the  diagnosis 
of  paresis  will  have  to  be  based  solely  upon  the  mental  manifes- 
tations of  the  disease.  The  symptoms  that  will  help  us  most 
in  arriving  at  this  diagnosis  are  defects  of  memory,  absence  of 
the  paranoiac  character,  and  the  slight  influence  of  the  delu- 
sions upon  the  patients'  acts  as  well  as  the  emotional  instability 
and  changeability. 

(3)  Manic  Depressive  Insanity.  In  this  affection  periodic 
delusions  of  a  paranoid  kind  are  not  infrequently  observed,  but 
the  fantastic  changeable  delusions  of  the  manic  depressive  pa- 
tient have  nothing  in  common  with  the  delusions  of  the  true 
paranoiac.  The  differential  diagnosis  is  not  difficult,  because 
as  a  rule  delusions  are  present  in  manic  depressive  insanity  only 
during  later  attacks  or  at  a  time  when  the  previous  history  and 
other  symptoms  have  determined  the  correct  diagnosis. 

(4)  Dementia  Senilis.  The  differential  diagnosis  between 
paranoid  delusions  occurring  during  the  course  of  senile  de- 
mentia and  those  that  are  encountered  in  a  true  paranoia  should 
cause  no  difficulty.  The  age  of  the  patient,  the  evidence  of  senil- 
ity, the  different  character  of  the  delusions,  the  disorders  of  at- 
tention, memory  and  intelligence  will  make  the  diagnosis  of 
senile  dementia  certain. 

(5)  Pre-senile  Delusional  Insanity.  Errors  in  diagnosis  be- 
tween paranoia  and  pre-senile  persecutory  delusional  insanity 
are  easily  possible,  since  this  latter  psychosis  begins  very  much 
like  paranoia.  In  its  further  course,  however,  delusions  set  in 
which  may  be  differentiated  from  those  of  true  paranoia  by  the 
following  characteristics ;  the  persecutory  ideas  of  senile  patients 
are  generally,  from  their  very  beginning,  fantastic  and  nonsen- 


PSYCHOSES  IN  GENERAL  229 

sical;  they  are  constantly  changing  and  are  not  combined  into 
a  fixed  delusional  system ;  they  are  susceptible  of  correction  and 
the  patient  may  be  convinced  of  their  fallacy ;  finally,  these  pre- 
senile delusions  of  persecution  rarely  or  never  exert  a  peremp- 
tory influence  upon  the  patient's  acts. 

6.    Mania,  Melancholia  and  Manic  Depressive  Insanity 

a.    MANIA 

Mania  is  a  disease  which  in  the  majority  of  instances  has  a 
tendency  to  recur  and,  as  explained  later,  it  may  appear  together 
with  melancholia,  in  which  case  the  affection  is  known  as  manic 
depressive  insanity.  Its  characteristic  emotional  state  is  a  purely 
expansive  one,  or  at  least  has  an  expansive  tendency,  and  when 
fully  developed  it  finds  its  expression  in  the  form  of  manic 
exaltation.  The  nature  of  this  excitation  may  be  either  joy- 
ous or  malevolent.  The  joyous  exaltation  is  known  as  euphoria. 
In  this  state  we  never  find  a  buoyant  tranquillity  which  by  force 
of  its  persistency  and  serenity  might  lead  to  weariness  and 
therefore  to  discomfort,  but  all  is  action  and  movement,  and  the 
inexhaustible  activity  of  all  emotional  processes  assures  a  con- 
stant change.  Nevertheless,  in  spite  of  this  pure  euphoria,  in- 
tercurrent displeasurable  affects  arise,  but  on  account  of  the 
rapid  flow  of  the  mental  processes  and  the  joyous  foundation 
upon  which  they  rest  they  can  never  gain  a  firm  hold.  Hence 
they  need  not  receive  the  attention  that  must  be  given  to  the 
displeasurable  affects  of  a  manic  depressive  psychosis. 

In  the  lighter  form  of  mania,  the  intellectual  processes  flow 
with  extraordinary  rapidity  and  the  intellectual  receptivity  for 
things  and  occurrences  in  the  surrounding  world,  as  well  as 
for  those  in  the  patient's  own  body,  is  markedly  heightened. 
While  a  poor  observer  will  overlook  many  things  that  are  quite 
apparent,  the  maniac,  because  of  the  rapidity  of  his  observa- 
tions, is  enabled  to  receive  relatively  more  impressions  than  even 
a  normal  person.  In  fact,  his  receptivity  is  not  only  more  rapid 
but  also  more  intense.  At  the  same  time  his  attentiveness  is 
augmented.  For  these  reasons  he  perceives  and  assimilates  a 
mass  of  details  that  surely  would  escape  the  attention  of  a  nor- 
mal individual. 


230    THE  UNSOUND  MIND  AND  THE  LAW 

All  this  applies  not  alone  to  the  perceptual  ability  but  also 
to  the  power  of  reproduction.  The  latter,  too,  is  increased  in 
rapidity,  readiness  and  vivacity.  Hence  the  patient's  powers 
of  association  grow  enormously  and,  because  he  has  not  time  for 
close  observation,  the  association  processes  are  immediately  set 
in  action  by  the  merest  points  of  superficial  similarity.  For  the 
same  reason  his  fantasy  is  boundless  and  the  elaboration  of  his 
perceptions  and  the  dependent  conclusions  and  judgment,  while 
not  adversely  affected,  certainly  are  abnormal.  The  required 
logical  operations  take  their  course  with  intense  dexterity  and 
precision  but  it  is  just  this  acceleration  of  the  mental  processes 
— particularly  the  rapid  sequence  of  the  intellectual  concepts — 
that  prevents  the  retentiveness  necessary  for  a  proper  sifting 
and  arranging  of  the  thought  material.  Similarly  hyper-facile 
association  that  takes  place  as  a  result  of  mere  superficial  simi- 
larities will  easily  lead  a  maniac,  even  of  high  intelligence, 
to  fallacious  deductions,  but  these,  when  occurring  in  the  lighter 
stages  of  the  disease,  are  subsequently  corrected.  In  the  mani- 
festations of  the  will,  as  well  as  all  the  other  factors  that  go  to 
make  up  the  intellect,  mania  is  characterized,  as  Meynert  ex- 
presses it,  by  a  luxuriousness  in  ''expression  and  movement." 
This  applies  particularly  to  the  voluntary  and  involuntary  ges- 
tures, including  the  facial  expressions,  which  being  almost  free 
from  control,  reflect  the  mental  processes  as  they  take  place. 
Moreover,  the  maniac  has  a  tendency  to  talk  incessantly — he  suf- 
fers from  "logorrhea" — and  all  his  speeches  revolve  about  him- 
self. In  the  lighter  form  of  mania  his  actions  are  still  actions  in 
the  true  sense — that  is,  they  still  arise  from  conscious  motives — 
but  as  the  will  as  a  whole  lacks  steadfastness,  his  plans  and  their 
dependent  acts  run  riot.  Although  endlessly  changing  plans  are 
formed,  only  a  small  part  of  them  is  carried  out  and  then  but 
incompletely.  Hardly  is  a  decision  reached  when  its  execution 
is  begun ;  but  at  the  same  time,  under  the  pressure  of  new  and 
perhaps  totally  different  thoughts  and  disorders,  a  new  and 
diametrically  opposed  determination  is  reached,  and  thus  the 
feverous  activity  comes  to  lack  all  uniformity  and  direction. 
Naturally  the  actions  cannot  keep  pace  with  the  formation  of 
motives.  For  instance,  motive  "A"  incites  to  action  "A"; 
while  the  latter  is  in  the  process  of  being  carried  out,  motives 
"B,"  "C"  and  "D"  are  beginning  to  have  their  effects;  as  a 


PSYCHOSES  IN  GENERAL  231 

result  action  "A"  is  not  followed  by  action  "B"  but  perhaps 
by  action  "D."  Hence  although  the  motives  themselves  may 
bear  a  perfectly  correct  sequence,  their  translation  into  actions 
bears  the  semblance  of  incongruity. 

Common  to  the  comportment  of  every  manic  patient,  no  mat- 
ter what  the  basal  effect  may  be,  are  his  unbounded  self -appre- 
ciation, persistent  restlessness,  haste  and  vehemence  in  all  fields 
of  mental  activity,  in  gesture,  movement,  gait,  word  and  acts ; 
also  his  feverous  activity,  a  tendency  not  only  to  excess  in  all 
forms  of  physical  enjoyment,  especially  in  the  use  of  alcoholic 
stimulants  and  tobacco,  but  also  to  excess  in  work. 

Every  mania,  therefore,  is  characterized  by  the  following 
symptoms : 

(a)  A  pathological  emotional  tone  in  the  nature  of  a  pro- 
longed causeless  excessive  joyousness,  accompanied  by  exalted 
self-importance  and  sometimes  also  by  ideas  of  grandeur  and  a 
tendency  to  outbreaks  of  rage; 

(b)  Verbal  excitement  in  the  nature  of  flight  of  ideas,  and 

(c)  Motor  excitement  expressing  itself  by  great  muscular 
activity  with  a  tendency  to  destructiveness  and  frenzy. 

The  entire  course  of  the  attack  may  be  divided  into  three 
periods.  The  initial  stage  is  characterized  by  headache,  lassi- 
tude and  sleeplessness.  Soon  a  change  sets  in ;  the  patients  be- 
come very  lively  and  joyous  and  all  their  work  is  done  with  the 
greatest  ease;  they  become  talkative  and  loquacious;  their  ges- 
tures and  expressions  become  vivacious,  they  taunt  the  people 
about  them  and  sneer  at  the  doings  of  every  one  they  know, 
play  all  kinds  of  practical  jokes  and  in  many  ways  offend  against 
the  requirements  of  good  behavior.  These  prodromal  manifes- 
tations often  are  not  looked  upon  by  the  people  about  the  patient 
as  evidence  of  disease.  A  most  noticeable  feature  in  the  second 
stage  is  the  senseless  activity,  the  loquaciousness,  the  incessant 
shifting  from  one  plan  to  another,  often  resulting  in  financial 
losses. 

Usually  all  these  symptoms  increase  rapidly  and  the  acme 
or  third  stage  of  the  disease  is  soon  reached.  The  patients  are 
in  constantly  joyous  mood.  They  sing,  dance,  laugh  and  tease 
every  one  about  them,  and  are  always  doing  something.  They 
manifest  an  exalted  appreciation  of  self  which  in  one  patient 
may  evidence  itself  as  a  harmless  braggadocio,  while  in  another 


232    THE  UNSOUND  MIND  AND  THE  LAW 

it  may  be  a  true  notion  of  grandeur.  They  deride  and  deprecate 
the  actions  of  others,  talk  much  of  themselves  and  their  accom- 
plishments, and  unduly  praise  everything  they  do.  A  distinct 
flight  of  ideas  exists  during  which  the  patients  skip  from  one 
subject  to  another  and  are  unable  to  carry  out  any  single  thought 
connectedly  to  its  logical  end.  A  conversation  with  them  may 
begin  with  a  few  correct  questions  and  answers,  but  soon  they 
digress,  revert  to  other  matters  and  become  flighty  in  their 
ideas  and  statements.  Finally  words  and  only  words  succeed 
one  another  with  automatic  rapidity ;  the  patients  talk,  vocifer- 
ate and  even  scream  until  they  become  hoarse.  One  thought 
association  follows  another  in  irregular  alternation,  the  sequence 
being  determined  by  sudden  sensory  impressions  or  by  mere 
similarities  of  sound.  The  thought  connections  of  the  maniac 
usually  are  merely  superficial.  The  entire  rhetoric,  interspersed 
by  numerous  rhymes,  play  upon  words  and  poetical  quotations, 
is  characterized  not  by  a  repleteness  of  ideas  but  by  a  copious- 
ness of  words.  Characteristic  withal  is  the  ease  with  which 
manic  patients  may  be  influenced.  Their  loquacity  may  easily 
be  turned  in  any  desired  direction  by  showing  them  any  object 
or  by  calling  to  them  any  word  stimulus,  for  the  new  stimulus 
is  immediately  adopted  and  associatively  elaborated.  Their 
motor  agitation  runs  parallel  with  their  verbal  excitement ;  this 
keeps  up  for  weeks,  and  the  continuous  muscular  activity 
and  loss  of  sleep  lead  to  marked  emaciation  of  the  body.  Manic 
patients  do  not  seem  to  know  fatigue.  They  dance  and  jump 
about,  tear  their  clothes,  become  violent  and  destroy  whatever 
comes  into  their  hands.  The  height  of  the  attack  is  followed 
by  a  regression  of  all  symptoms.  The  patients  become  fatigued, 
sleep  returns  for  hours  at  a  time,  flight  of  ideas  becomes  modified 
into  loquacity,  the  motor  excitement  into  a  kind  of  bustling 
activity  and  then  recovery  usually  takes  place. 

In  many  instances  of  hypomania,  the  pathological  quality  can 
be  recognized  merely  by  the  noticeable  alteration  of  character 
and  the  resulting  abnormal  actions.  The  psycho-motor  and 
speech  excitation  remain  within  moderate  bounds,  while  the 
euphoric  basal  tone  becomes  markedly  prominent.  Hypomania 
may  best  be  identified  by  the  acts  to  which  it  leads.  The  patients 
tend  to  excesses  of  various  kinds,  in  eating  and  drinking  and  all 
sorts  of  extravagances.     On  account  of  their  retained  self-con- 


PSYCHOSES  IN  GENERAL  233 

trol,  their  responsiveness,  and  the  precision  of  reasoning  that 
often  exists,  by  means  of  which  they  explain  and  define  their 
extraordinary  actions,  these  persons  are  never  recognized  as 
insane  by  the  layman. 

Delusions,  particularly  of  an  expansive  and  paranoid  nature, 
occur  as  a  rule  only  in  the  more  severe  attacks  of  mania.  They 
are  generally  variable  and  either  slightly  or  not  at  all  system- 
atized, but  frequently  they  are  characterized  by  a  fantastic 
confabulatory  impress.  The  clinical  picture  of  mania  is  there- 
fore an  extraordinarily  varied  one.  At  one  time  the  euphoric, 
at  another  the  passionate  emotions  will  predominate;  first 
psycho-motor  excitement  and  then  delusion  will  be  most  in  evi- 
dence; now  the  general  course  may  be  mild  and  again  it  may 
be  violent.  When  the  affection  runs  its  typical  course  and 
is  at  its  acme  all  the  symptoms  of  classic  mania  will  be  found 
present.  Sometimes  the  psycho-motor  excitement  reaches  such 
heights  that  the  patients  give  vent  only  to  inarticulate  sounds 
and  execute  only  incoordinate  movements.  Exceptionally,  at 
the  height  of  the  disease,  illusions  and  hallucinations  set  in, 
orientation  is  lost,  the  connectedness  of  concepts  becomes  com- 
pletely severed  and  a  state  of  confusion  exists.  This  state  of 
delirious  mania  usually  lasts  but  a  few  days. 

Differential  Diagnosis 

The  differential  diagnosis  of  mania  must  be  made  from  the 
following : 

(1)  Dementia  Paralytica.  In  every  mania  that  occurs,  par- 
ticularly in  men  between  the  thirtieth  and  fortieth  years,  the 
first  thought  should  be  of  a  paresis,  for  states  of  maniacal  excite- 
ment may  occur  in  the  beginning  as  well  as  during  the  course 
of  this  disease.  The  somatic  symptoms  of  an  organic  brain 
disease  and  the  signs  of  mental  decline  will  furnish  the  differ- 
entiating evidence. 

(2)  Dementia  Prgecox.  The  earlier  incidence  of  this  dis- 
ease, the  katatonic  accompaniments  and  the  mental  deterioration 
will  identify  the  manic  or  hypomanic  states  of  a  dementia 
prsecox. 

(3)  Acute  Hallucinatory  Insanity.  This  may  also  present 
considerable   similarity   to  mania,    but   the   preponderance    of 


234     THE  UNSOUND  MIND  AND  THE  LAW 

hallucinations,  the  disorder  of  perception  and  apperception, 
together  with  the  absence  of  true  flight  of  ideas,  will  reveal  the 
trouble  in  its  true  light. 

(4)  Agitated  Melancholia.  Exceptionally  a  mania  may 
resemble  an  agitated  melancholia,  or  a  maniacal  epileptic  or 
hysterical  state,  but  the  characteristics  typical  of  the  latter  will 
prevent  error  in  diagnosis. 

Forensic  Aspects 

The  maniac  easily  comes  into  conflict  with  the  law.  Above  all 
these  conflicts  will  be  the  result  of  his  exuberant  affect  and  will 
take  the  form  of  injuries  to  person,  insults  of  all  kind,  breach 
of  the  peace,  homicide  and  by  no  means  infrequently  sexual 
crimes.  Moreover  forgery,  theft,  fraud,  and  alcoholic  excesses, 
with  all  their  unfortunate  results,  are  often  committed. 

B.      MELANCHOLIA 

Melancholia  is  an  affection  the  characteristics  of  which  may  be 
classified  as  follows: 

(1)  Melancholia  always  emanates  from  the  emotional  and  not 
from  the  intellectual  sphere. 

(2)  In  melancholia  we  are  always  and  necessarily  dealing 
with  an  emotional  depression. 

(3)  In  addition  the  will  is  always  depressingly  affected. 

(4)  This  is  always  and  necessarily  accompanied  by  an  inhi- 
bition of  the  conceptual  processes,  the  thought  contents  always 
being  of  a  sorrowful  nature. 

In  addition,  the  affection  has  the  following  negative  charac- 
teristics : 

(1)  It  is  not  necessarily  dependent  upon  degenerative  causes, 
but  may  arise  in  a  primarily  healthy  brain. 

(2)  In  the  intellectual  field  there  exists  no  disorder  except 
the  inhibition  of  conceptual  processes  already  mentioned  and, 
aside  from  the  sorrowful  coloration  of  the  concepts,  no  disorder 
need  be  present. 

The  chief  point  to  be  remembered  in  melancholia  is  that  the 
affection  starts  from  the  emotional  and  not  from  the  intellectual 
field.  The  intellectual  disorders  that  occur  in  this  disease  must 
be  looked  upon  as  secondary  to  the  emotional  ones,  yet  once  the 


PSYCHOSES  IN  GENERAL  235 

emotional  disorder  has  carried  a  disturbance  of  the  intellect  in 
its  train,  a  mutational  relationship  becomes  established  between 
the  two.  It  is  this  factor,  namely  that  the  first  impetus  emanates 
from  the  emotional  and  not  from  the  intellectual  sphere,  that 
constitutes  the  decisive  differentiation  from  paranoia,  in  which 
the  intellectual  disorder  furnishes  the  groundwork  for  the 
disease. 

When  we  say  that  melancholia  is  based  upon  an  emotional  dis- 
turbance, we  mean  an  emotional  depression  which  varies  in 
degree  in  accordance  with  the  severity  of  the  melancholia.  More- 
over, it  is  always  a  question  of  a  sorrowful  depression.  A  sor- 
rowful depression  is  of  itself  by  no  means  necessarily  patho- 
logical, but  is  a  physiological  psychic  process.  The  healthiest 
person  is  subject  to  grief,  and  the  person  who  never  becomes 
depressed  is  an  anomaly.  To  that  extent  the  melancholiac  does 
not  differ  from  the  non-melaneholiac.  Besides,  the  exciting 
causes  of  the  depression  may  be  the  same  in  both,  and  they  are 
as  different  as  it  is  possible  for  them  to  be.  In  a  thousand  in- 
stances the  melancholiac  will  ascribe  his  sorrow  to  causes  which 
would  produce  sorrow  in  anybody.  Of  course  individual  dis- 
position, educational  and  social  conditions  will  account  for  a 
difference  in  the  ease  of  creation  and  the  intensity  of  the  sorrow. 

What,  then,  constitutes  the  difference  between  a  melancholiac 
and  the  person  who  is  normally  depressed  ?  The  answer  to  this 
question  may  be  sought  in  the  intensity  of  the  depression — that 
is,  in  the  mental  disproportion  between  cause  and  effect — for  a 
cause  which  in  a  normal  person  would  create  a  feeling  of  slight 
discomfort  will  plunge  the  melancholiac  into  actual  despondency ; 
or  else  it  may  be  sought  in  the  persistency  of  the  affect,  for  a 
thing  that  otherwise  produces  a  brief  depression  will  bring 
about  a  more  or  less  enduring  result  in  the  case  of  the  melan- 
choliac, or,  to  state  it  in  a  different  way,  things  that  the  normal 
person  considers  entirely  irrelevant  may  be  sources  of  psychic 
pain  for  the  melancholiac.  All  these  points,  including  the  one 
last  mentioned,  might  be  explained  by  a  peculiar  disposition 
or  a  hypersensitiveness  which  still  lies  within  normal  bounds, 
for  there  is  no  way  of  regulating  the  human  mind  in  its  estima- 
tion of  any  particular  cause  for  sorrow  or  pleasure  and  it  would 
be  entirely  wrong  to  expect  the  reaction  of  an  average  person, 
who  remains  impassive  under  certain  circumstances  merely  be- 


236    THE  UNSOUND  MIND  AND  THE  LAW 

cause  he  is  superficial,  to  be  the  same  as  that  of  a  more  intense 
nature  which  under  similar  conditions  would  find  ample  cause 
for  despondency. 

These  considerations  show  us  how  difficult  or  impossible  it 
may  be,  in  the  lighter  cases,  to  depend  upon  the  factor  of  sor- 
rowful depression  for  the  determination  of  the  existence  of  a 
melancholia.  The  sorrowful  depression  characteristic  of  mel- 
ancholia must  possess  still  another  quality.  This  is  an  augment- 
ing tendency  to  overwhelm  the  personality  of  the  affected  per- 
son, to  falsify  his  mental  outlook  to  such  an  extent  that  he  him- 
self and  every  one  about  him  appear  in  somber  colors,  as  though 
viewed  through  dark  glasses.  Nowhere  can  the  patient  see  a  ray 
of  light,  and  conditions  and  occurrences  in  his  own  body  or 
outside  of  it  that  should  ordinarily  arouse  joyous  feelings  serve 
only  as  new  causes  for  despondency.  Ultimately  there  exist  for 
him  no  pleasurable  affects.  His  intellectual  life  will  necessarily 
be  involved  by  this  pessimistic  perceptual  transmutation.  All 
in  all  the  consciousness  of  the  melancholiac  is  not  disordered, 
and  particularly  the  power  of  conclusion  and  judgment  remains 
intact.  Hence  he  will  search  for  reasons  to  explain  the  occur- 
rence of  his  painful  affects  and  these  he  will  find  not  in  things 
outside  of  himself,  things  that  are  beyond  his  powers  of  control 
and  for  which  he  is  not  responsible,  but  in  his  own  defects  and 
derelictions.  Therein  we  find  a  further  essential  factor  of 
melancholia. 

The  thought  contents  of  the  melancholiac  are  always  perme- 
ated by  the  notion  that  he  himself  is  at  fault.  The  self -accusa- 
tions he  makes  he  then  seeks  to  substantiate  by  every  possible 
means,  and  during  the  lighter  stages  of  the  trouble  he  utilizes 
for  this  purpose  pessimistically  distorted  or  exaggerated  repre- 
sentations of  occurrences  from  his  early  life.  The  varieties  of 
such  self-accusations  are  as  manifold  as  life  can  make  them. 
Whatever  might  be  morally  or  legally  looked  upon  as  a  source 
of  wrong  will  be  dragged  forth  for  purposes  of  self-accusation. 
Under  all  conditions,  therefore,  an  obscuration  of  the  thought 
contents  will  be  brought  about  and  disorder  of  the  intellect  in- 
evitably follows.  This  disorder  is  revealed  primarily  by  the  in- 
hibition already  mentioned.  Hence  we  also  find  melancholia 
always  characterized  by  an  inactivity  of  the  will.  The  longer 
the  disease  lasts,  the  more  the  patient  becomes  convinced  of  a 


PSYCHOSES  IN  GENERAL  237 

diminution  of  his  capabilities  and  hence  of  a  lowering  of  his 
personal,  vocational  and  social  worth,  and  this,  on  account  of 
his  continuous  tendency  to  interpret  everything  in  the  sense  of 
his  displeasurable  affects,  he  inordinately  exaggerates.  In  view 
of  his  firm  conviction  of  his  incompetency  the  patient,  believing 
it  to  be  entirely  futile  to  make  any  demands  upon  his  will  power, 
does  so  less  and  less.  As  a  result  the  breakdown  of  his  will 
power  continues  in  an  increasing  degree. 

The  psychic  inhibition  that  has  been  brought  about  by  the 
dominating  psychic  depression  acts  in  its  turn  as  an  independ- 
ent source  of  displeasure  and  thus  the  vicious  circle  in  which  the 
total  personality  of  the  patient  moves  becomes  more  and  more 
complete.  When  the  circle  is  actually  completed  there  exists 
a  fear  of  coming  into  contact  with  other  people,  a  lowering  of 
self-confidence,  a  feeling  of  utter  unworthiness  and  culpability, 
self-accusations  and  despair.  That  this  state  may  cause  the 
patient  to  be  indifferent  toward  obligations  devolving  upon  him 
is  to  be  expected  from  the  very  nature  of  the  trouble,  and  this 
apparent  neglect  of  duty  will  be  attributed  by  others  to  indo- 
lence or  laziness.  Not  only  are  obligations  shirked  and  legal 
complications  caused  thereby,  but  even  pronounced  unlawful 
acts  may  result  from  an  outbreak  of  despair.  The  outbreak  may 
set  in  suddenly,  without  any  apparent  outward  explanation,  the 
depression  itself  through  its  persistent  monotony  having  passed 
beyond  the  bounds  of  the  endurable,  or  it  may  be  brought  about 
by  any  purely  accidental  extraneous  cause.  On  the  other  hand, 
the  outbreak  of  despair  may  not  set  in  suddenly,  but  may  be  a 
motor  manifestation,  more  or  less  enduring  and  noticeable,  as  a 
result  of  which  the  patient  manifests  a  form  of  restless  activity 
that  may  be  misinterpreted  as  a  return  of  energy  and  health  but 
which  actually  is  part  of  the  morbid  agitation.  Inasmuch,  how- 
ever, as  return  of  energy  and  manifestations  of  activity  may  also 
be  an  expression  of  approaching  cure,  it  is  easy  to  see  the  dif- 
ficulties attending  the  correct  interpretation  of  the  condition, 
especially  from  a  forensic  point  of  view. 

In  women  melancholia  usually  begins  at  the  age  of  forty-five 
to  fifty-five  (climacteric),  and  in  men  somewhat  later,  but 
not  before  the  fiftieth  year.  The  beginning  of  a  melancholia 
is  always  a  state  of  simple  depression  and  may  extend  over  weeks 
and  months.     The  patients  become  sorrowful  without  cause, 


2.38  THE  UNSOUND  MIND  AND  THE  LAW 

are  no  longer  able  to  conduct  their  work  properly,  become  taci- 
turn and  self-centered  and  give  expression  to  all  kinds  of  vague 
fears.  They  lose  interest  in  their  own  sphere  of  existence,  de- 
rive no  pleasure  from  anything,  and  become  complaining  and 
timid.  Loss  of  appetite  and  sleep  is  an  early  symptom  that  is 
never  wanting.  Typical  of  the  initial  stage  of  melancholia  are 
a  peculiar  restlessness  and  undecidedness.  Now  and  then  self- 
accusatory  and  suicidal  ideas  become  manifest.  At  the  height 
of  the  disease  we  find  an  unvarying  constant  deep  affect  which 
manifests  itself  in  every  possible  expression  of  pain,  at  one  time 
by  suppressed  crying  and  whining,  at  another  by  loud  complaints 
and  disconsolate  wringing  of  the  hands.  This  sorrowful  depres- 
sion is  frequently  interrupted  by  states  of  fear.  These  may  set 
in  at  once  with  full  force  (raptus  melancholicus)  or  may  only 
gradually  reach  their  complete  intensity.  They  demonstrate 
themselves  by  marked  agitation  and  an  incessant  purposeless 
running  to  and  fro,  by  constant  monotonous  plaints  and,  not  in- 
frequently, by  dangerous  attempts  against  the  patient's  own 
life  or  others.  The  states  of  fear  may  pass  by  rapidly  or  may 
last  for  weeks.  Often  they  recur  at  certain  hours  of  the  day, 
particularly  in  the  early  morning.  The  fear  itself  is  most 
always  a  typical  precordial  anxiety. 

In  the  majority  of  melancholiacs  delusions  develop  very  early. 
The  delusion  of  sinfulness  is  most  often  observed  and  next  in 
frequency  is  that  of  impoverishment.  The  patients  pass  in  re- 
view their  entire  previous  lives  and  everywhere  find  the  taint 
of  evil  deeds.  Some  deduce  their  delusional  ideas  from  a  definite 
occurrence,  usually  of  an  entirely  harmless  nature,  recalled 
from  the  far  distant  past.  For  instance,  they  may  remember 
having  refused  to  give  alms  to  a  beggar  or  having  tortured  an 
animal  or  having  failed  to  disapprove  with  sufficient  force  some 
improper  proposal  made  to  them ;  and  consequently  they  have 
been  cast  off  and  no  longer  desire  to  live.  Sometimes  the  de- 
pressive delusions  revolve  entirely  about  religious  questions ;  the 
patients  accuse  themselves  of  not  having  gone  to  church  often 
enough,  they  have  sinned  against  God  and  his  laws,  and  for 
this  reason  they  are  doomed  to  eternal  punishment.  Not  infre- 
quently the  delusion  of  sinfulness  is  associated  with  one  of  sus- 
picion. From  the  expressions  and  questions  of  those  about 
them  the  patients  are  sure  they  are  being  derided,  scorned  and 


PSYCHOSES  IN  GENERAL  239 

cursed.  In  the  majority  of  instances  the  actual  basis  upon 
which  the  depressive  delusion  is  built  becomes  amplified  by  de- 
lusions of  a  hypochondriacal  and  paranoid  nature.  The  latter 
are  never  systematized  and  do  not  in  any  way  influence  the 
patient's  conduct.  The  melancholiac  is  a  "persecute  passif." 
He  justifies  and  excuses  the  supposed  persecutions  and  at- 
tributes them  to  his  own  unworthiness  and  his  sinfulness  against 
God  and  the  world.  The  hypochondriacal  delusions  usually 
occur1  only  episodically  and  are  accompaniments  more  par- 
ticularly of  the  earlier  and  later  stages  of  the  psychosis.  Delu- 
sions of  transformation  and  obsession  are  of  only  exceptional 
occurrence. 

The  depression  in  a  melancholiac,  as  already  stated,  receives 
its  specific  impress  from  the  concomitant  existence  of  psycho- 
motor and  general  thought  inhibition,  and  accordingly  we  find 
such  patients  without  power  of  decision,  lacking  in  energy,  and 
unable  to  arouse  themselves  to  any  positive  action.  Their  move- 
ments are  slow;  often  they  will  sit  motionless  for  hours  as 
though  transfixed,  having  the  same  stereotyped  melancholic  ex- 
pression and  a  persistent  stare,  with  infrequent  blinking  of 
the  eyelids.  The  play  of  features  is  limited  and  displays  none 
but  the  feelings  of  sorrow  and  fear.  Often  we  notice  the  melan- 
choliac pressing  his  hand  to  the  region  of  the  heart.  The  gen- 
eral inhibition  of  thought  is  shown  by  the  monotonous  makeup 
of  the  delusions,  by  the  slow,  drawn-out  manner  of  speech  and 
by  the  exceedingly  sparse  store  of  words.  Many  of  the  patients 
will  not  make  use  of  a  dozen  or  two  different  words  for  weeks 
and  months  at  a  time.  Sometimes  a  short  expression  of  com- 
plaint, or  the  exclamation,  "My  God,  my  God,"  constitutes 
the  sole  verbal  accomplishment. 

Deceptions  of  the  various  senses  illusions,  hallucinations  of 
hearing  and  not  infrequently  also  &f  taste  and  smell  are  ac- 
companiments of  the  psychosis.  The  patients  hear  themselves 
reproached,  accused,  scolded,  or  threatened.  They  see  their  en- 
tire surroundings  turning  deep  red,  or  the  people  about  them 
suddenly  becoming  black.  Appalling  figures  become  visible, 
they  hear  the  moans  caused  by  the  suffering  of  their  starving 
and  dying  children,  everything  smells  of  dirt  or  noxious  emana- 
tions. All  in  all  the  sense  deceptions  do  not  play  a  great  role 
in  the  disease ;  it  is  only  when  they  are  present  during  the  states 


240     THE  UNSOUND  MIND  AND  THE  LAW 

of  fear  that  they  assume  an  active  influence,  and  they  then  con 
stitute  the  cause  for  dangerous  attacks. 

A  tendency  to  suicide  and  refusal  of  food  is  encountered  in 
nearly  every  melancholiac.  The  patients  are  usually  inalterably 
persistent  in  their  attempts  at  self-destruction  and  plan  them 
with  a  cunning  that  stands  in  peculiar  contrast  to  their  psycho- 
motor and  general  thought  inhibition.  Once  the  opportunity  is 
found,  the  execution  is  forceful  and  sure.  The  refusal  to  take 
food  may  either  be  due  to  an  effort  to  die  by  starvation  or  else 
it  is  the  result  of  depressive  hypochondriac  or  paranoid  delu- 
sions, the  patients  believing  their  food  to  be  poisoned  or  them- 
selves unworthy  of  eating,  unable  to  digest  their  food,  etc. 

The  conception  of  the  surrounding  world,  orientation,  in- 
telligence and  memory  are  not  disordered,  broadly  speaking. 
Only  in  that  exceptional  delusion  in  which  their  entire  sur- 
roundings appear  appallingly  transformed  do  the  patients  have 
any  illusionary  distortion  of  persons  and  things. 

According  to  the  predominance  of  individual  symptoms  dm 
ing  the  course  of  the  psychosis  we  may  differentiate  the  fol- 
lowing : 

(a)  Melancholia  simplex,  in  which  the  sorrowful  depres- 
sion dominates,  while  more  marked  delusions  and  apprehensive 
excitement  are  absent. 

(o)  Melancholia  amxiosa,  in  which  the  affect  is  one  of 
intense  fear  and  discharges  itself  as  a  permanent  motor  rest- 
lessness. 

(c)  Melancholia  stupor osa,  in  which  inhibition  predom- 
inates, so  that  the  highest  degree  of  retardation  of  the  entire 
psychomotor  and  conceptual  life  is  reached. 

According  to  the  contents  of  the  delusions  we  speak  of  a 
hypochondriacal,  a  religious  or  a  persecutory  melancholia.  This 
classification,  however,  has  very  little  value,  because  almost 
every  melancholia  at  some  time  of  its  course  presents  delusions 
of  various  kinds. 

An  attack  of  melancholia  lasts  on  the  average  from  eight  to 
fourteen  months  and  is  accompanied  by  loss  in  weight,  digestive 
disturbances  and  other  physical  disorders.  The  prognosis, 
especially  in  melancholia  simplex,  is  favorable  in  the  majority 
of  instances.  It  becomes  less  favorable  (1)  the  more  rapidly 
\he  sorrowful  affect  disappears  and  gives  way  to  apathy;  (2), 


PSYCHOSES  IN  GENERAL  241 

the  more  the  hypochondriacal  and  paranoiacal  delusions  come 
into  the  foreground  and  the  more  nonsensical  are  their  contents ; 
(3)  when  there  is  present  a  "delire  des  negations''  (nihilistic 
delusions),  in  which  the  patients  believe  the  entire  world  has 
been  destroyed  and  everything-  is  merely  a  semblance  and 
symbol  of  former  things,  or  a  "delire  d'enormite"  in  which  the 
patients  believe  themselves  to  be  monsters  of  wickedness,  or 
when  true  notions  of  grandeur  exist;  (4)  the  nearer  the  patient 
is  to  senile  involution  and  the  more  pronounced  the  physical 
signs  of  senility  are;  (5)  when  there  is  present  the  melancholic 
derisiveness  that  in  some  cases  sets  in  after  the  psychosis  has 
lasted  for  months. 

Forensic  Aspects 

Melancholia  often  gives  cause  for  medico-legal  consideration, 
particularly  on  account  of  the  acts  of  violence  to  which  it  leads. 
Practically  the  question  is  usually  one  of  criminalistic  import, 
although,  of  course,  civil  suits  for  damages  may  follow  as  a  re- 
sult of  acts  of  violence  that  have  been  committed.  But  the 
passive,  apathetic,  inactive  state  of  the  melancholiac  may  also 
attain  forensic  significance  on  account  of  the  neglect  of  duty 
and  obligations  it  may  entail.  Questions  of  this  kind  have  not 
been  of  great  practical  significance,  however.  On  the  other 
hand,  acts  of  violence  committed  by  melancholiacs  often  occupy 
the  attention  of  the  courts.  They  occur  in  more  or  less  typical 
forms,  particularly  damage  to  property,  incendiarism,  bodily 
injury,  self -mutilation,  murder  and  suicide,  the  latter  not  only 
as  direct  suicide,  but  also  as  indirect  suicide.  The  patient  who 
is  too  cowardly  to  kill  himself  may  commit  a  crime  punishable 
by  death  in  order  to  bring  about  his  own  destruction  by  the 
hand  of  justice. 

In  the  lighter  kinds  and  stages  of  melancholia  it  will  always 
be  difficult  to  prove  with  certainty  the  existence  of  the  disease, 
particularly  since  the  resulting  disorder  of  intelligence  is  but  a 
restricted  one  and  the  majority  of  patients  appear  to  the  aver- 
age observer  to  conduct  themselves  no  different  from  other 
people  of  somewhat  serious  disposition.  Moreover  such  patients 
are  in  general  able  to  follow  their  occupation  without  noticeable 
difficulty  and  consequently  the  morbid  indolence  and  its  prae- 


242    THE  UNSOUND  MIND  AND  THE  LAW 

tical  manifestations  are  attributed  to  a  weakness  of  character. 
On  the  other  hand,  when  stupor  or  hallucinations  are  present, 
the  recognition  of  the  disease  is  easy,  even  for  the  layman  A 
great  aid  in  the  estimation  of  these  cases  is  the  fact  that  the 
acts  of  violence  committed  by  melancholiacs  possess  no  motive 
outside  of  the  desire  to  free  themselves  from  the  ban  of  their 
torturing  mental  tension.  The  more  violent,  unprovoked  and 
horrible  the  outbreak,  the  more  are  we  warranted  in  assuming 
the  existence  of  disease. 

Differential  Diagnosis 

The  differential  diagnosis  of  melancholia  must  be  made  from 
the  following: 

(1)  Dementia  Paralytica.  The  emotions  of  the  paretic 
are  changeable.  He  is  undecided  and  weeps  easily.  The  melan- 
choliac,  however,  is  unvaryingly  depressed  and  weeps  little,  if 
at  all.  The  affect  in  the  melancholiac  is  deeper,  hence  his  re- 
fusal to  take  food  is  usually  more  energetic  than  that  of  the 
depressed  paretic  patient.  The  latter,  on  the  contrary,  often 
eats  remarkably  well.  Depressed  patients  who  pass  urine  and 
feces  uncontrolledly  should  be  suspected  of  having  paresis. 
All  somatic  symptoms,  speech  disorders,  pupilary  rigidity,  etc., 
of  course  speak  for  a  paresis.  This  disease  occurs  most  fre- 
quently between  the  ages  of  thirty  and  forty-five,  melancholia 
between  forty-five  and  fifty-five. 

(2)  Senile  Dementia.  The  differential  diagnosis  may  often 
be  difficult.  The  disorders  of  memory  for  recent  events,  de- 
fects of  intelligence  and  the  physical  symptoms  of  old  age  favor 
the  diagnosis  of  senile  dementia. 

(3)  Paranoia.  This  disease,  in  a  patient  at  an  advanced 
age,  may  at  its  onset  present  a  picture  similar  to  that  of  melan- 
cholia. The  suspicious,  timid,  irritable  behavior,  the  more 
pronounced  sense  deceptions,  the  absence  of  inhibition,  the 
illusions  of  hearing  and  often  also  the  facial  expression  will 
differentiate  the  paranoiac  from  the  melancholiac.  The  former 
will  say,  "I  may  have  done  one  thing  or  another  that  was  not 
right,  but  how  does  that  concern  others,  and  why  am  I  being 
persecuted?"  The  melancholiac,  on  the  other  hand,  says,  "I  am 
being  oppressed  and  harrowed  and  they  want  to  get  rid  of  me 


PSYCHOSES  IN  GENERAL  243 

but  that  is  perfectly  right  and  just,  for  I  deserve  no  other  treat- 
ment, miserable  creature  that  I  am!" 

(4)  Manic  Depressive  Insanity.  This  disease  occasionally 
does  not  begin  until  the  period  of  involution  and  then  the  de- 
pressive stage  may  resemble  melancholia.  The  diagnosis  can  be 
made  only  when  several  attacks  or  manic  phases  have  been  ob- 
served, for  the  cardinal  symptoms  of  melancholia  and  the  de- 
pression in  manic  depressive  insanity  are  entirely  similar. 

C.      MANIC  DEPRESSIVE  INSANITY 

Just  as  the  occurrence  of  a  single  attack  of  a  simple  mania  is 
very  unusual,  so  a  typical  depressive  psychosis  as  a  single 
episode  in  a  person's  life  history  is  very  rare.  Both  mania  and 
depression  tend  to  recur.  In  three-quarters  of  all  instances 
the  first  attack  of  periodic  and  circular  insanity  is  observed  be- 
fore the  twenty-fifth  year  of  life.  In  almost  every  instance  we 
find  short  states  of  depression  preceding,  interrupting,  or  fol- 
lowing the  manic  phases,  or  else  manic  states  preceding,  inter- 
rupting or  joining  the  depressive  phases.  Mixed  states  are 
most  often  observed  at  the  time  when  one  phase  passes  into 
another. 

There  exist  individual  instances,  however,  in  which  typical 
manic  or  depressive  phases  do  not  occur,  but  are  represented 
by  equivalents  in  the  shape  of  mixed  states.  Simple  or  classical 
mania,  periodic  insanity  (periodic  mania,  periodic  melancholia), 
as  well  as  circular  insanity,  are  classed  by  Kraepelin  as  manic 
depressive  insanity.  The  only  cases  to  be  classed  as  simple  or 
classical  mania  are  those  in  which  but  one  attack  of  mania  oc- 
curs during  the  individual's  entire  life.  As  stated  before,  such 
cases  are  extraordinarily  infrequent.  There  are  other  cases  in 
which  several  maniacal  attacks,  separated  from  one  another  by 
long  intervals,  occur  in  a  person's  life.  These  form  a  transition 
to  periodic  mania,  a  psychosis  in  which  we  find  a  more  or  less 
regular  cycle  of  attacks  extending  throughout  the  person's  en- 
tire life.  Correspondingly,  the  term  melancholia  serves  to  desig- 
nate those  instances  in  which  several  melancholic  attacks,  sep- 
arated by  free  intervals,  have  occurred  during  a  person's  life. 
On  the  other  hand,  circular  insanity  comprises  those  cases  in 
which  manic   and  melancholic   attacks  alternate,  in  some  in- 


244    THE  UNSOUND  MIND  AND  THE  LAW 

stances  being  separated  by  free  intervals  and  in  others  being 
without  any  intermission. 

The  transitions  between  all  these  forms  are  indefinite.  Par- 
ticularly is  it  impossible  to  determine  a  distinct  dividing  line 
between  periodic  mania  and  circular  insanity.  In  every  periodic 
mania,  melancholic  attacks  probably  also  occur.  A  division  of 
manic  depressive  insanity  into  different  types  is  not  in  accord- 
ance with  clinical  facts.  A  perfectly  regular  course,  as  for  in- 
stance, a  pure  periodic  mania,  is  extraordinarily  rare.  Usually 
the  maniacal  attacks  are  interspersed  with  attacks  of  other 
nature,  the  typical  course  of  the  disease  being  thereby  inter- 
rupted. 

Of  the  manic  phase  of  manic  depressive  insanity  there  is 
little  to  be  said  that  has  not  already  been  stated  under  the  re- 
marks on  mania.  Very  often,  however,  these  manic  states  are 
so  light  in  character  that  they  represent  no  more  than  an  ex- 
uberance, an  exaltation,  a  swinging  of  the  depressive  pendulum 
in  an  opposite  direction.  Then  the  over-activity  may  manifest 
itself  in  an  excess  of  vice  or  of  intellectual  energy.  So  in  many 
periodic  drinkers,  the  attack  of  alcoholism  usually  is  followed 
by  a  period  of  depression,  representing  a  manic  phase  of  a 
manic  depressive  psychosis.  These  remarks  apply  also  to  some 
authors  and  composers  whose  work  is  periodic  and  is  always 
colored  by  the  exuberant  state  during  which  it  has  been  accom- 
plished. There  exist  many  manic  depressive  persons  who  never 
are  recognized  as  being  insane,  whose  entire  life  consists  of  a 
constant  alternation  of  light  mania  and  depressive  states.  Such 
periodists  often  appear  as  though  suddenly  transformed,  become 
talkative,  jovial  and  industrious.  Flight  of  ideas  and  psycho- 
motor excitement  as  a  rule  are  wanting,  while  increased  self- 
appreciation  and  euphoria  clearly  exist. 

The  depressive  phase  of  the  disease  with  all  its  symptoms  con- 
stitutes a  clear  antithesis  to  the  manic  phase.  It  is  characterized 
by  a  persisting,  causeless,  sorrowful  depression,  as  well  as  by 
an  inhibition  of  the  will  and  of  the  conceptual  processes.  The 
sorrowful  depression  often  sets  in  quite  suddenly.  The  patients 
no  longer  find  pleasure  in  anything  and  become  indifferent  to 
their  own  interests.  Some  become  dispirited  and  resigned, 
others  tearful  and  still  others  apprehensively  excited.  The 
psycho-motor  inhibition  (inhibition  of  the  will)  develops  on  a 


PSYCHOSES  IN  GENERAL  245 

parallel  with  the  sorrowful  depression  and  soon  ends  in  com- 
plete indetermination.  The  patients'  bodies  are  relaxed,  their 
attitude  crouching  and  they  gaze  about  sorrowfully  and  help- 
lessly, making  but  few  spontaneous  movements.  Only  with  dif- 
ficulty can  they  force  themselves  to  even  the  simplest  actions,  as 
those  of  dressing  and  eating.  When  asked  to  do  any  definite 
thing,  as  for  instance  to  lift  the  right  arm,  they  respond  with 
manifest  difficulty,  slowly  and  incompletely.  This  inhibition  of 
the  will  also  becomes  apparent  in  their  speech,  which  is  often 
low  in  tone  and  dragging.  The  course  of  their  conceptual  proc- 
ess is  distinctly  retarded  and  monotonous.  The  patients  can 
remember  but  with  difficulty  many  of  the  things  with  which 
they  formerly  were  thoroughly  conversant.  Psychic  accomplish- 
ments, such  as  writing  a  letter,  or  conducting  a  simple  con- 
versation, though  formerly  carried  out  with  ease,  now  become 
impossible.  The  patients  must  consider  before  they  can  re- 
spond to  the  most  simple  questions  and  even  then  their  replies 
are  retarded  and  drawn  out. 

In  manic  depressive  insanity  various  forms  of  depression  may 
be  distinguished,  differing  from  one  another  according  to  the 
intensity  of  the  different  symptoms.  In  mildly  depressive  states 
with  slight  inhibition,  the  patients  become  monosyllabic,  re- 
served and  indifferent.  Their  thought  processes  and  actions 
are  slow  and  awkward  and  only  those  occupations  to  which  they 
have  been  most  accustomed  can  be  carried  out.  In  pronounced 
sorrowful  depression  with  slight  inhibition,  the  pathological 
affect  predominates  and  at  times  becomes  so  great  as  to  consti- 
tute the  most  distressing  fear.  Patients  thus  afflicted  are  deeply 
unhappy,  despair  of  everything,  give  vent  to  their  self-accusa- 
tory thoughts  and  are  suicidal.  Another  form  is  made  up  of  de- 
pression with  delusions  accompanied  by  various  degrees  of  in- 
hibition. Here  the  delusional  contents  are  predominantly  de- 
pressive and  are  made  up  mostly  of  ideas  of  sinfulness,  though 
paranoid  and  hypochondriacal  delusions  are  not  infrequent. 
Still  another  form  is  designated  as  depressive  stupor.  Here 
complete  inhibition  exists  and  is  most  profound,  while  the  affect 
manifests  itself  only  in  the  particularly  disturbed  physiognomy 
which  plainly  reflects  the  patient's  complete  helpless  perplexity. 
The  patients  are  apprehensively  restless,  gaze  about  confusedly, 
make  short,  abrupt  nervous  movements  and  are  incapable  of  ut- 


246     THE  UNSOUND  MIND  AND  THE  LAW 

tering  a  word  or  of  exercising  any  coordinate  activity.  Not  in- 
frequently they  pass  nrine  and  feces  involuntarily  and  must  be 
fed.  Sometimes  the  depressive  stupor  is  associated  with  states 
of  fear  and  sense  deceptions,  in  which  disorientation  and  deep 
disturbances  of  consciousness  exist.  Frequently,  later,  the  recol- 
lection of  these  states  is  very  faulty.  A  special  form  of  depres- 
sion, finally,  is  the  so-called  "melancolie  raisonndnte."  In  this 
the  sorrowful  depression  is  more  or  less  intense  and  the  lack  of 
will  power  complete.  Nevertheless  the  patients  have  full  in- 
sight into  their  condition,  criticise  their  depressive  thoughts 
with  astonishing  perspicacity  and  have  the  most  intense  desire 
for  relief  from  their  condition. 

We  have  seen  that  mania  and  melancholia,  and  hence  also  the 
manic  as  well  as  the  depressive  phases  of  manic  depressive  in- 
sanity, are  characterized  by  three  corresponding  cardinal  symp- 
toms. In  the  psycho-motor  field  we  have  in  the  one  instance 
excitement,  in  the  other  inhibition;  the  emotional  field  is  char 
acterized  in  the  one  phase  by  euphoria,  in  the  other  by  depres- 
sion; and  in  the  conceptual  field  we  find  upon  the  one  hand 
flight  of  ideas,  in  the  other  retardation  of  thought  process.  Not 
infrequently  specific  episodes  take  place  in  the  manic  as  well 
as  in  the  depressive  phase  of  manic  depressive  insanity,  in  which 
the  symptomatology  of  the  attack  is  represented  by  a  combina- 
tion of  manic  and  depressive  manifestations.  The  main  forms 
of  these  mixed  states  are: 

(1)  Manic  Stupor.  This  state  follows  upon  a  typical  manic 
exaltation  with  flight  of  ideas.  The  patients  abruptly  become 
quiet,  the  psycho-motor  excitement  passes  over  into  a  more  or 
less  marked  inhibition  and  it  is  only  by  the  peculiar  physiog- 
nomic expression,  the  peculiar  wooden,  masklike  smile,  that  the 
oasal  manic  mood  may  be  recognized.  Sometimes  the  manic 
stupor  arises  in  the  midst  of  a  depressive  stupor,  in  which  case 
the  previous  deeply  sorrowful,  apprehensively  excited  physiog- 
nomic expression  becomes  transformed  into  a  contrasting 
euphoric  one. 

(2)  Agitated  Depression  with  Flight  of  Ideas.  This  state 
also  arises  from  the  typical  manic  exaltation,  the  euphoria  be- 
coming transformed  into  a  depression,  while  all  other  symptoms 
of  the  manic  phase,  flight  ideas  and  motor  excitement,  persist 
unaltered. 


PSYCHOSES  IN  GENERAL  247 

(3)  Manic  Inhibition  of  Thought  Processes.  In  this  state 
both  symptoms  of  the  manic  phase,  euphoria  and  motor  excite- 
ment, are  present,  but  there  is  no  flight  of  ideas.  Instead  there 
is  a  pronounced  disturbance  of  speech  productions  which  often 
gives  a  distinct  impression  of  feeble-mindedness.  In  the  place 
of  flight  of  ideas  there  exists  inhibition  of  thought  processes. 
This  may  easily  be  demonstrated  if  the  patient  be  drawn  into 
conversation,  if  an  arithmetical  problem  be  given  to  him  to 
solve  or  if  his  intelligence  be  tested  in  some  other  manner. 
Then  the  retardation  and  laboriousness  of  the  powers  of  thought 
and  judgment  become  evident.  Of  course,  the  questions  asked 
must  be  adapted  to  the  patient's  degree  of  culture.  The  dura- 
tion of  an  individual  attack  varies.  The  manic  as  well  as  the 
depressive  phase  may  last  for  weeks  and  months;  very  rarely 
do  they  last  for  years.  The  average  duration  is  two  to  four 
months.  The  first  attacks  are  usually  followed  by  a  prolonged 
free  interval,  which  may  continue  for  years.  Later  the  attacks 
become  more  frequent  and  the  free  intervals  shorter.  The  prog- 
nosis of  the  individual  attack  is  good.  Except  for  a  certain 
apathy  and  enfeeblement  of  will  power  which  may  remain  per- 
manently after  frequent  attacks,  recovery  generally  takes  place. 

It  should  be  remembered,  however,  that  manic  depressive  in- 
sanity is  a  disease  in  which  hereditary  taint  plays  an  important 
part  and  that  the  intervals  between  the  individual  phases  are, 
therefore,  always  tinged  by  this  constitutional  makeup  as  well 
as  by  the  apathy  and  enfeebled  will  power.  For  this  reason,  the 
disease  often  cannot  be  looked  upon  forensically  as  one  with 
"free  intervals,"  but  must  be  considered  as  a  continuous  or 
permanent  state. 

Differential  Diagnosis 

On  account  of  the  alternations  of  manic  and  depressive  phases 
with  remissions  that  occur  in  some  cases  of  katatonia,  these  may 
be  mistaken  for  manic  depressive  insanity.  A  careful  analysis 
of  the  manifestations,  however,  will  reveal  distinct  differences. 
The  manic  patient  may  be  diverted;  not  so  the  katatonie.  Im- 
portant and  of  decisive  value  is  the  facial  expression.  In  the 
katatonie  we  encounter  empty  masklike  traits  or  grimaces  and 
tics,  in  the  manic  stuporous  patient  a  tense  sardonic  euphoria 


248    THE  UNSOUND  MIND  AND  THE  LAW 

and  in  the  depressive  stuporous  patient  a  disturbed  apprehen- 
sive facial  expression.  Moreover  true  flight  of  ideas  does  not 
occur  in  katatonia. 

Some  cases  of  paresis  may  be  remindful  of  manic  depressive 
insanity,  but  aside  from  the  psychic  symptoms  of  paretic  de- 
mentia, somatic  signs  of  paresis  will  be  demonstrable. 

Forensic  Aspects 

The  medico-legal  relations  of  a  manic  depressive  psychosis 
will  in  the  manic  phase  be  those  of  a  mania  and  in  the  depressed 
phase  those  of  a  melancholia  and  their  estimation  except  in  very 
mild  cases  should  occasion  no  difficulties.  In  the  mild  cases  the 
social  complications  may  be  so  great  that  they  may  lead  to 
charges  of  insubordination,  neglect  of  duty  and  neglect  of  fam- 
ily obligations,  and  yet  the  patients  may  not  be  recognized  as 
insane. 

A  much  more  difficult  problem,  however,  is  the  estimation  of 
the  forensic  relations  of  the  intervals  between  the  various  phases, 
as  well  as  the  intervals  between  the  attacks.  Both  of  these 
periods  may  be  of  comparatively  short  duration  and  at  the  same 
time  be  free  from  recognizable  mental  anomalies.  Consequently 
there  may  be  danger  that  these  intervals  will  be  looked  upon 
forensically  as  "lucid  intervals"  in  which  a  patient  supposedly 
has  temporarily  regained  his  reason  and  is,  therefore,  legally 
not  insane.  From  a  medical  point  of  view  there  can  be  no  such 
1 '  lucid  intervals, ' '  for  every  well-defined  form  of  mental  disease 
has  its  well-defined  course  and  duration  and  it  is  immaterial 
whether  at  one  period  or  another  certain  symptoms  are  in  abey-, 
ance  or  not.  So  long  as  the  disease  persists,  it  will  take  its 
course  even  if  short  periods  of  apparent  mental  health  are  inter- 
spersed or  not.  The  intervals  between  the  phases  of  a  manic 
depressive  psychosis,  however,  represent  something  entirely  dif- 
ferent. The  patient  is  insane  for  the  period  of  the  individual 
phase,  but  not  for  that  of  the  interval.  Mental  disease  has  pre- 
ceded and  we  know  mental  disease  will  follow.  Yet  even  during 
the  interval  all  those  characteristics  which  constitute  the  psychic 
personality  of  the  individual,  and  which  furnish  the  soil  upon 
which  the  disease  itself  flourishes,  will  continue  to  be  present. 
Upon  the  number  and  intensity  of  these  intervallary  symptoms 


PSYCHOSES  IN  GENERAL  249 

will  depend  the  estimation  of  each  individual  case  and  the 
judicial  determination  as  to  whether  the  person  was  incom- 
petent or  irresponsible  at  the  particular  time.  The  essential 
point  is  not  that  the  patient  happens  to  be  at  a  period  between 
two  phases  of  mental  disorder.  The  entire  mental  state  at  the 
time  of  the  examination,  considered  in  combination  with  what 
has  gone  before  and  what  is  to  come  after,  will  have  to  be  the 
deciding  factor. 


II 

THE  NEUROPSYCHOSES 

1.   Hysteria 

Hysteria  is  an  abnormal  mental  state  based  upon  an  inherited 
taint.  The  cardinal  symptom  consists  in  a  morbidly  exag- 
gerated suggestibility  for  all  concepts  that  relate  to  the  patient 's 
own  personality.  These  concepts,  acquired  in  part  through 
auto-suggestion,  in  part  through  extraneous  influences,  control 
the  entire  nervous  system  in  a  directly  imperative  manner,  ex- 
ert their  action  upon  the  motor,  the  sensory,  the  secretory  and 
the  vaso-motor  nerve  conductions  and  bring  about  an  entire 
series  of  functional  nervous  manifestations.  The  latter  in  turn 
are  characterized  by  the  fact  that  they  may  be  made  to  disap- 
pear by  concepts  of  an  antagonistic  nature,  implanted  either 
by  auto-suggestion  or  by  hetero-suggestion,  in  a  way  that  would 
seem  almost  miraculous  to  the  lay  observer. 

The  word  "hysteria"  indicates  that  the  disease  has  its  seat  in 
the  uterus.  This  would  lead  us  to  infer  that  hysteria  is  a  specific 
disease  of  women.  Such,  however,  is  not  the  case.  Numerous 
observations  have  shown  that  hysteria  occurs  in  men  as  well, 
though  with  less  frequency  than  in  women.  For  this  reason  it  has 
been  proposed  to  replace  the  term  "hysteria,"  a  name  which 
has  become  entirely  inadequate,  by  that  of  ' '  psychogeny. ' '  This 
new  term  lays  stress  upon  the  inmost  nature  of  the  hysterical 
state,  viz.,  the  fact  that  all  hysterical  symptoms,  the  psychic  as 
well  as  the  physical  ones,  may  be  produced  essentially  by  ab- 
normally strong  concepts  and  influenced,  as  well  as  annulled, 
by  the  same  means. 

Hysteria  develops  upon  the  groundwork  of  a  primary  ab- 
normal disposition.  Often  the  main  characteristics  of  the  hys- 
terical personality  are  indicated  in  early  childhood  and  not 
infrequently  all  the  distinctive  marks  of  hysteria  will  be  found 
already  present  in  the  child.  The  disease  usually  attains  its 
full  development  around  the  time  of  puberty. 

250 


THE  NEUROPSYCHOSES  251 

In  every  instance  the  diagnosis  of  hysteria  may  be  based  in 
the  main  upon  these  two  essential  factors: 

(1)  The  basis  of  hysteria  is  constituted  by  a  permanent 
psychic  abnormal  state  whose  chief  characteristic  is  represented 
by  the  hysterical  personality. 

(2)  Upon  this  basis  all  kinds  of  nervous  and  psychic  dis- 
orders occur  episodically  and  these  are  signalized  by  their  de- 
pendence upon  concepts  and  counter  concepts. 

Hysteria  may  develop  in  individuals  who  are  well  developed 
intellectually  as  well  as  in  the  feeble-minded  and  in  those  who 
are  morally  defective.  Hence  the  hysterical  personality  does 
not  represent  a  concrete  type.  We  will  always  find  it  to  be  made 
up,  however,  of  a  certain  number  of  typical  sharply  defined 
states.     These  are  the  following: 

(1)  Instability.  Hysterics  are  extraordinarily  unstable;  their 
mood  is  constantly  changing;  states  of  depression  give  way  to 
states  of  excited  rage.  At  one  time  such  patients  will  be  over- 
sensitive and  easily  aggrieved,  shedding  torrents  of  tears  upon 
the  slightest  provocation;  at  another  they  will  be  reserved, 
indifferent  and  malevolent.  Now  they  will  intrigue,  slander 
every  one  about  them  and  create  disturbance  and  discord,  and 
again  they  will  be  profuse  in  self-accusation,  acknowledge  all 
their  faults  and  dwell  protractedly  upon  their  own  wicked- 
ness. Besides  they  are  unstable  in  their  activities.  Tem- 
porarily they  may  manifest  a  morbid  energy  in  the  promotion 
of  any  notion  that  dominates  them  and  whose  realization  de- 
mands that  they  play  a  certain  role.  But  this  exhibition  of 
energy  is  usually  followed  by  complete  abandonment.  Per- 
sistency of  action  is  wanting.  Moodiness,  momentary  im- 
pulses, sympathies  and  antipathies  determine  all  their  actions. 

(2)  Suggestibility.  In  accordance  with  their  uncertain  char- 
acter, all  hysterical  individuals  are  influenced  with  extraor- 
dinary ease.  They  are  very  susceptible  to  external  impressions 
and  everything  new  that  presents  any  interest  has  particular 
attraction  for  them. 

(3)  Negativism:  In  contradistinction  to  their  enormous 
suggestibility  and  not  infrequently  directly  associated  with  it, 
hysterics  often  manifest  an  accentuated  negativistic  attitude 
during  which  nothing  can  be  obtained  from  them  except  by 
contrary  statements  and  in  which,  unapproachable  as  they  are 


252    THE  UNSOUND  MIND  AND  THE  LAW 

for  any  extraneous  influences,  they  impose  all  kinds  of  depriva- 
tion upon  themselves  and  continue  to  suffer  with  obstinate  per- 
sistence. It  is  then  we  so  often  observe  mutism  and  a  most 
obstinate  refusal  to  take  food. 

(4)  Love  for  notoriety.  Mostly  all  hysterics  have  a  tendency 
to  push  themselves  everywhere  into  the  foreground.  Their 
romantic  self-accusations,  their  sensational  confabulations, 
their  self-mutilation  and  their  well-staged  attempts  at  suicide, 
all  have  but  one  purpose — that  of  making  themselves  the  center 
of  attention;  the  more  debased  the  woman  hysteric  is  from  a 
moral  point  of  view  the  less  will  she  refrain  from  the  most  dis- 
graceful deeds,  and  she  will  lie,  simulate,  slander  and  even  steal 
in  order  to  attain  her  purpose  of  winning  personal  attention. 

(5)  Egotism.  The  love  for  notoriety  is  merely  a  marked 
manifestation  of  the  egotism  of  hysterics.  All  their  attention 
is  directed  exclusively  toward  themselves,  and  they  give  them- 
selves up  with  the  greatest  intenseness  and  persistency  to  a 
study  of  their  physical  and  mental  states.  The  slightest  dis- 
turbance in  their  sense  of  health  will  receive  the  most  pro- 
found attention  and  find  an  outlet  in  the  most  exaggerated 
complaints.  Withal  they  are  indifferent  to  the  sufferings  of 
their  associates,  they  constantly  demand  special  care  and  con- 
sideration, believe  themselves  to  be  neglected  and  are  jealous 
and  envious  of  everybody  else.  Ultimately  the  state  of  being 
sick  becomes  a  necessity  for  them  and  they  enact  this,  their 
calling,  with  the  entire  masterly  skill  that  the  hysterical  tem- 
perament has  placed  at  their  disposal.  Here  it  is  that  the 
extraordinarily  mobile  dramatic  talent  so  characteristic  of  the 
hysteric  becomes  so  helpful  to  them.  Notwithstanding  the  pur- 
poseful exhibition  of  their  martyrdom,  hysterics  are  often  not 
unappreciative  of  the  pleasures  of  life  and  usually  are  greedy, 
vain  and  inquisitive. 

(6)  The  tendency  to  confabulation.  Truth  and  fiction  are 
usually  so  intimately  associated  in  hysterics  that  they  them- 
selves, being  no  longer  able  to  differentiate  between  the  two, 
finally  believe  their  own  inventions  to  be  actual  occurrences. 
For  this  reason  we  must  not  always  look  upon  the  confabula- 
tions of  hysterics  as  conscious  deceptions,  but  must  consider 
that  they  may  be  falsifying  in  good  faith. 

(7)  The   tendency  to  simulation.     This  is  very  frequently 


THE  NEUROPSYCHOSES  253 

encountered  in  hysterics.  Expectoration  of  blood,  fever, 
paralysis,  refusal  to  take  food  and  many  other  serious  symp- 
toms of  disease  have  been  simulated  by  hysterics,  more  or  less 
adroitly,  so  that  laparotomy  and  other  major  operations  have 
been  carried  out  when,  as  appeared  later,  they  were  not  at  all 
necessary. 

Upon  the  basis  of  the  permanently  abnormal  state  that  we 
have  just  sketched  and  which  may  be  designated  as  a  psychic 
degeneration,  the  bodily  symptoms  of  hysteria  develop  and 
manifest  themselves  partly  as  symptoms  of  nerve  irritation, 
partly  as  symptoms  of  nerve  destruction.  These  symptoms  are 
characterized  by  their  dependence  upon,  and  their  capability 
of  being  influenced  by,  ideas.  This  is  shown  by  the  following 
facts: 

(a)  The  attention  that  hysterics  bestow  upon  themselves  or 
which  is  given  them  by  other  persons  (members  of  the  family, 
physicians,  etc.)  usually  produces  an  increase  in  their  symp- 
toms, so  that  tremor,  pain,  speech  disorders,  etc.,  become  more 
pronounced. 

(b)  Strong  affects  increase,  ameliorate  or  annul  the  symp- 
toms. Not  infrequently  contractures,  paralyses,  etc.,  of  an  hys- 
terical nature  supervene  after  strong  emotions  (fear  or  fright) 
just  as,  upon  the  other  hand,  functional  disorders  may  disap- 
pear under  the  influence  of  marked  psychic  excitement. 

(c)  Symptomatically,  suggestion  reinforced  by  electricity, 
hypnotism  or  any  indifferent  medicament  has  a  decided  in- 
fluence upon  the  production  as  well  as  upon  the  amelioration 
and  abolition  of  hysterical  states.  In  this  connection  I  would 
refer  to  my  book  on  Suggestion  and  Psychotherapy,  in  which 
the  theory  of  psychogenic  diseases  and  their  treatment  by 
psychogenic  measures  are  elaborated. 

The  most  important  bodily  disorders  of  hysterics  are  the 
following : 

(A)  Disorders  of  sensation.  These  consist  in  anesthesias  and 
hypereesthesias,  occurring  either  alone  or  in  combination. 
Anaesthesia  is  the  most  frequent  and  may  be  spread  over  the 
entire  body  or  may  occur  hemilaterally  or  regionally.  In  the 
latter  case  the  anaesthesia  never  corresponds  to  the  anatomical 
distribution  of  the  nerve,  but  covers  the  entire  extremity  or 
certain  parts  of  the  extremity  limited  by  the  joints  (hand  or 


254     THE  UNSOUND  MIND  AND  THE  LAW 

foot),  or  it  is  diffused  over  different  portions  of  the  body  that 
bear  no  anatomical  or  physiological  relationship  to  one  another. 
Frequently  the  mucous  membranes  also  are  anaesthetic.  The 
hyperaesthesias  show  the  same  irregularities  of  localization  as 
do  the  anaesthesias.  They  may  occur  anywhere  and  to  any  ex- 
tent. Very  frequent  are  the  neuralgic  pains.  Particularly  fre- 
quent are  the  boring,  circumscribed  pain  in  the  forehead  or 
upon  the  occiput  known  as  clavus;  the  sensation  of  a  ball  mov- 
ing up  and  down  in  the  throat  or  closing  it  (globus)  ;  sensitive- 
ness along  the  spinal  column  (spinal  irritation),  and  pain  upon 
pressure  in  the  region  of  the  ovaries.  The  anaesthesias  and 
hyperaesthesias  may  often  be  made  to  disappear  by  the  applica- 
tion of  magnets  or  by  means  of  other  suggestive  measures,  but 
they  will  reappear  at  some  other  place.  This  manifestation  has 
been  designated  as  transferi.  Pressure  upon  the  hyperaesthetic 
areas  will  often  bring  about  convulsive  attacks  (hysterogenic 
zones). 

(B)  Disorders  of  special  sense.  The  most  frequent  of  these 
is  concentric  restriction  of  the  visual  field ;  less  frequent  is  a 
reduction  of  visual  acuity.  Diminution  of  the  color  sense 
(dyschromatopsia)  as  well  as  complete  loss  of  color  sense 
(achromatopsia)  are  also  encountered.  Of  these  achromatopsia, 
usually  occurring  unilaterally,  is  most  frequent.  Transitory 
disturbances  of  hearing  are  rare,  but  disturbances  of  the  sense 
of  smell  and  taste  are  more  frequently  observed. 

(C)  Disorders  of  motility.  These  are  tremor,  disturbances  of 
speech,  convulsions,  paralyses  and  contractures. 

The  tremors  manifest  themselves  as  trepidation  of  the  eyelids, 
nystagmus,  trembling  of  the  extended  fingers,  spontaneous 
tremor  in  various  extremities. 

The  hysterical  disorders  of  speech  are  stuttering  and  stam- 
mering. Not  infrequently  we  encounter  hysterical  (psycho- 
genic) paralyses  of  the  vocal  cords  (aphonia). 

The  hysterical  convulsions  may  be  classed  as  rudimentary, 
light  and  severe.  The  rudimentary  convulsive  attacks  occur  in 
juvenile  hysteria  as  well  as  in  the  very  beginning  of  the  dis- 
ease when  it  develops  in  later  life.  They  consist  of  a  transitory 
clinching  of  the  hands,  slight  distortion  of  the  arms,  clonus  of 
the  lids  and  rolling  of  the  eyeballs,  or  in  short  laryngeal  spasms 
with  rapid  respirations.     The  light  convulsive  attacks  are  the 


THE  NEUROPSYCHOSES  255 

most  frequent.  They  are  made  up  mainly  of  the  epileptoid 
period  of  the  grande  attaque;  the  two  phases  being  absent  or 
but  weakly  indicated.  The  severe  convulsions  may  in  accord- 
ance with  the  terminology  of  the  Charcot  school  be  divided  into 
four  phases: 

(1)  An  Epileptoid  Period.  This  ordinarily  begins  without  a 
cry,  the  entire  musculature  of  the  body  stiffens,  the  hands  be- 
come clinched,  the  head  is  slowly  turned  backward,  the  eyes  are 
rolled  upward,  the  face  is  distorted  and  the  extremities  slowly 
become  convulsed.  Then  follow  a  sharp  rapid  jerking  of  the 
hands,  a  twitching  of  the  face,  of  the  other  extremities  and  then 
a  short  respite.    This  period  lasts  from  two  to  five  minutes. 

(2)  A  Period  of  Extensive  Movements.  This  begins  with  the 
posture  so  characteristic  of  hysteria,  known  as  "arc  de  cercle," 
in  which  the  body,  bent  like  an  arch  with  the  convexity  up- 
ward, rests  only  upon  the  head  and  feet.  During  this  period 
the  entire  body  stiffens  as  in  a  katatonic  and  may  be  turned  or 
lifted  like  a  dead  weight.  After  from  two  to  ten  minutes  the 
extensive  movements  set  in  and  each  hysterical  individual  may 
have  certain  movements  that  are  peculiar  to  him  and  to  the 
attack  with  which  we  are  dealing.  Some  patients  will  beat  their 
breasts  with  their  fists,  others  will  turn  and  roll  the  head  or  the 
entire  body,  others  will  wallow  upon  the  floor  and  perform  all 
kinds  of  unrelated  incoordinate  movements.  Sometimes  these 
"grandes>  mouvements"  have  a  monotonous  stereotyped  char- 
acter. 

(3)  A  Period  of  Emotional  Attitudes.  This  follows  upon  the 
"periode  des  grandes  mouvements"  without  any  sharp  dividing 
line  and  is  made  up  of  constantly  changing  theatrical  poses  and 
dramatic  gestures.  This  period  lasts  from  five  to  ten  min- 
utes. 

(4)  A  Period  of  Delirium.  This  phase  follows  directly  upon 
the  preceding  one  and  is  a  period  of  twilight  consciousness,  dur- 
ing which  the  attack  exhausts  itself.  Single  memory  deceptions 
set  in  the  unconsciousness  disappears  and  gradually  orientation 
returns.  This  period  may  last  for  minutes  or  hours.  Fre- 
quently it  is  followed  by  paralyses,  contractures  and  other  hys- 
terical symptoms.  Sometimes  it  passes  over  into  an  hysterical 
insanity. 

Hysterical  paralyses  are  encountered  as  hemiplegias,  mono- 


256    THE  UNSOUND  MIND  AND  THE  LAW 

plegias  or  paraplegias.  Moreover  we  meet  with  an  inability  to 
walk  (abasia)  and  to  stand  (astasia)  and  less  frequently  with 
hysterical  speech  disorders. 

Hysterical  contractures  affect  the  extremities  so  that  they 
usually  maintain  a  posture  corresponding  to  that  of  any  one 
momentary  phase  of  the  convulsion  and  appear  as  though 
molded  into  that  posture.  These  hysterical  contractures  differ 
from  the  organic  ones  by  the  great  complexity  of  the  position 
of  the  affected  extremities,  by  the  absence  of  an  associated  facial 
weakness  or  facial  paralysis,  by  their  usual  association  with 
hemiansesthesia  and  by  their  sudden  occurrence.  The  organic 
contractures  usually  develop  slowly. 

(Z>)  Disorders  of  a  secretory  and  vaso-motor  nature.  These 
are  hemilateral  or  circumscribed  sweating,  stasis,  cedema,  etc.; 
these  also  may  be  influenced  psychically. 

(E)  Hysterical  disorder  of  the  gastra-intestinal  tract.  The 
symptoms  occasionally  encountered  are  a  globus  sensation  in 
the  abdomen,  eructations,  meteorism  and  vomiting. 

(F)  Other  bodily  disorders.  Temperature  increase  (hys- 
terical fever)  and  tachycardia  of  psychic  origin  have  been  ob- 
served. 

Hysterical  insanity  in  a  more  restricted  sense  represents 
those  states  that  usually  occur  episodically  upon  the  basis  of  a 
permanently  existing  hysterical  temperament,  are  associated 
with  marked  obscuration  of  consciousness  and  are  similar  to 
true  psychoses.  The  following  disorders  may  here  be  differ- 
entiated : 

(a)  Somnambulic  states.  The  patients  suddenly  arise,  wan- 
der about  as  though  fully  conscious  and  carry  out  actions  that 
may  be  orderly  or  ridiculous,  or  exceptionally  of  a  criminal 
nature  (theft,  incendiarism,  etc.),  then  fall  into  a  deep  sleep 
and  subsequently,  upon  awakening,  have  total  or  partial 
amnesia.  Retrograde  amnesia  also  may  follow.  Such  attacks 
occur  at  night,  but  may  set  in  during  the  daytime,  particularly 
after  a  convulsive  attack.  While  in  such  a  state  the  patients 
are  completely  reactionless,  or  can  be  awakened  only  with  dif- 
ficulty by  means  of  external  irritants. 

(b)  Hysterical  twilight  states.  These  occur  most  frequently 
before  or  after  the  major  attack  (pre-  and  post-hysterical  twi- 
light states).     Immediately   following  the  "periode   des  atti- 


THE  NEUROPSYCHOSES  257 

tudes  passionelles"  a  state  of  hallucinatory  delirium  sets  in 
during  which  consciousness  is  more  or  less  obscured.  The 
nature  of  the  delirium  is  usually  given  by  experiences  of  a 
particularly  exciting  kind,  disinterred  from  the  far  past  and 
lived  over  again  by  the  patient  with  extraordinary  sensory 
plasticity,  the  visionary  scenes  being  accompanied  by  marked 
hallucinations  of  hearing.  Visual  illusions  of  an  appalling 
kind  are  also  frequent,  the  patient  seeing  wild  animals,  snakes 
and  lions  in  the  act  of  attacking  him,  somber  apparitions  armed 
with  dangerous  weapons,  coffins  containing  relatives,  etc.  Pro- 
nounced dramatic  gesticulations,  marked  play  of  features, 
vague  paranoiac  notions  and  often  an  affected  drawling  man- 
nerism accompany  this  state,  which  passes  rapidly  over  into  one 
of  complete  consciousness.  Occasionally  there  exist  states  of 
religious  ecstasy  in  which  the  patient  sees  celestial  images  and 
has  the  facial  expression  of  one  who  is  in  a  beatific  state.  The 
hysterical  twilight  states  are  followed  by  a  loss  of  memory  of 
greater  or  less  extent.  This  amnesia  may  disappear  in  a  subse- 
quent twilight  state,  during  which  the  patient  lives  through 
and  elaborates  scenes  similar  to  those  experienced  in  the  previ- 
ous twilight  state.  In  some  cases,  however,  there  may  be 
alternation  of  clear  consciousness  and  twilight  state  so  that  the 
patient  lives  in  a  kind  of  double  consciousness,  in  that  upon 
the  one  hand  the  experiences  of  the  individual  delirious  phases 
bear  an  associative  relationship  to  each  other,  while  upon  the 
other  the  experiences  of  the  lucid  phases  only  are  associatively 
combined,  and  the  transition  between  them  is  a  disconnected 
and  unconscious  one.  In  such  a  delirious  stage  hysterics  will 
sometimes  believe  themselves  back  in  an  earlier  period  of  life, 
even  in  that  of  childhood,  and  then  they  will  talk,  act  and  con- 
duct themselves  in  conformity  with  the  illusionary  situation. 
Thus  the  contrast  between  the  delirious  and  the  lucid  stages 
becomes  still  more  marked  and  we  may  fittingly  speak  of  the 
existence  of  a  double  personality.  These  hysterical  twilight 
states  have  often  occurred  episodically,  and  this  was  particu- 
larly so  during  the  middle  ages. 

(c)  Manic  states  of  excitement.  Such  states  occur  trans- 
itorily, particularly  in  youthful  hysterics.  They  are  char- 
acterized  by    a   continuous   affectation   of   speech,   by   foolish 


258    THE  UNSOUND  MIND  AND  THE  LAW 

euphoria  with  frequent  laughter,  by  marked  erotic  traits  and  a 
tendency  to  nonsensical  acts. 

(d)  Hysterical  states  of  depression.  Such  states  may  as  a 
rule  be  easily  recognized  by  the  presence  of  pronounced  evi- 
dence of  an  hysterical  character.  Inhibition  is  either  very 
slight  or  is  entirely  absent. 

The  prognosis  of  hysteria  is  unfavorable.  While  it  is  true 
that  defects  of  intelligence  or  dementia  never  set  in,  the  con- 
genital psychopathic  state  permanently  remains.  The  trans- 
itory disorders  of  body  or  mind  present  a  good  prognosis. 
They  disappear  without  leaving  any  trace  as  soon  as  the  cor- 
rect remedy,  that  is,  the  proper  suggestion,  has  been  found. 

Differential  Diagnosis 

Before  arriving  at  a  diagnosis  of  hysteria,  we  must  exclude 
a  series  of  other  states  in  which  symptoms  and  conditions  very 
suggestive  of  hysteria  occur.     These  states  occur  as  follows: 

(A)  In  all  possible  diseases  of  the  train  and  spinal  cord 
(tumors  of  the  brain,  echinococcus  of  the  brain,  tabes,  dissem- 
inated sclerosis,  etc.).  In  such  instances  the  examination 
should  be  a  most  careful  one  in  order  to  ascertain  whether  the 
existing  symptoms  can  be  explained  anatomically  by  means  of 
any  definite  localized  lesion,  which  of  course  could  not  be  the 
case  in  hysteria. 

(B)  In  a  series  of  other  functional  (psychogenic)  mental  dis- 
orders.   These  are: 

(1)  Dementia  simplex  and  dementia  katatonia.    A  dif- 

ferential diagnosis  of  these  psychoses  has  already 
been  considered. 

(2)  Melancholia.    Here,  as  we  have  shown  in  the  chapter 

on  melancholia,  the  differential  diagnosis  cannot 
be  difficult. 

(3)  In  hystero-hypochondriasis.     This  differential  diag- 

nosis will  be  considered  in  the  proper  chapter. 

(4)  In  the  neuro-psychoses  due  to  accident.    These  cases 

of  hysteria  are  called  "traumatic  hysteria"  and 
constitute  an  important  factor  in  medico-legal  con- 
tests of  a  civil  nature,  particularly  in  the  deter- 
mination of  claims  for  damages  made  on  account 


THE  NEUROPSYCHOSES  259 

of  loss  resulting  from  accident.  In  consequence 
of  the  tendency  possessed  by  all  hysterics  to  ex- 
aggerate inordinately  their  sufferings  it  is  not 
always  easy  for  the  expert  psychiatrist  to  deter- 
mine accurately  which  of  the  injuries  to  health 
that  are  claimed  to  exist  are  actually  the  result 
of  the  accident  and  which  ones  must  be  attributed 
to  a  previously  existing  hysteria.  Light  can  best  be 
shed  upon  this  question  by  a  careful  anamnesis.  Of 
importance  for  differential  diagnosis,  moreover,  is 
the  fact  that  the  symptomatology  of  cases  of  trau- 
matic hysteria  is  usually  a  much  more  monotonous 
one  than  is  that  of  the  traumatic  neurosis  in  which 
there  is  no  hysterical  element. 
(5)  In  epilepsy.  The  differential  diagnosis  between  hys- 
teria and  epilepsy  will  be  discussed  explicitly  in 
the  chapter  on  epilepsy. 

Forensic  Aspects 

The  medico-legal  relations  that  obtain  in  hysteria  are  extraor- 
dinarily important  in  criminal  cases  as  well  as  in  contentions 
of  civil  law.  Not  only  is  the  comportment  of  hysterics  charac- 
terized by  a  subtlety  so  extraordinary  that  it  is  often  very 
difficult  to  demonstrate  the  actuality  of  their  complaints,  but 
also  the  testimony  of  such  hysterics  must  be  accepted  with  the 
utmost  reserve.  The  majority  of  acts  through  which  the  hys- 
teric comes  into  conflict  with  the  criminal  law  depend  upon 
the  particular  hysterical  state  in  which  they  are  committed. 
Thus  the  offenses  committed  during  the  transitory  twilight 
states  are  thefts  that  are  carried  out  as  a  result  of  desires  that 
arise  impulsively  or  have  been  carried  over  from  the  waking 
state.  Incendiarism  is  committed  under  analogous  conditions. 
In  still  other  instances  we  are  required  to  deal  with  the  per- 
verse impulsive  desires  that  arise  in  hysterical  individuals  after 
pregnancy,  acute  diseases,  etc. 

Most  of  the  hysteric  shoplifters,  swindlers  and  adventurers, 
however,  are  morally  defective  individuals,  as  are  also  those 
hysterics  who  calumniate,  slander  and  write  anonymous  accu- 
sations.    It  is  often  impossible  to  draw  a  line  between  these 


260    THE  UNSOUND  MIND  AND  THE  LAW 

hysterics  and  the  psychic  inferiors  of  whom  we  shall  speak  later 
on,  and  the  determination  of  responsibility  and  irresponsibility 
in  them  is  one  of  the  most  difficult  tasks  for  which  the  aid  of 
the  expert  is  sought.  Hysterics  attract  our  attention  also  by 
their  inability  to  narrate  in  a  simple,  correct  way  the  occur- 
rences that  have  come  within  their  knowledge.  They  combine 
the  actual  happenings  with  their  fantastic  inventions  in  such 
a  manner  that  a  true  picture  cannot  be  obtained.  The  hysteric 
who  is  called  as  a  witness  in  court  thus  may  become  a  menace 
to  justice.  The  statements  of  such  a  person,  when  uncorrobo- 
rated, must  be  accepted  with  the  greatest  reserve.  Particularly 
frequent  are  the  false  accusations  of  a  sexual  nature  that  are 
brought  by  hysterics  against  people  with  whom  they  have  had 
differences  of  any  kind.  Denunciations  of  physicians  with  ac- 
cusations of  having  committed  sexual  assault  upon  their  female 
patients  are  of  constant  occurrence. 

2.   Neurasthenia 

The  term  "neurasthenia"  is  used  to  designate  a  large  number 
of  different  states.  No  matter  how  the  term  has  been  used  it 
always  has  referred  to  a  number  of  conditions  that  occupy  the 
borderline  between  mental  health  and  mental  disease  and  which, 
notwithstanding  the  congenital  or  acquired  somatic  or  psychic 
abnormalities,  cannot  be  classed  among  the  true  insanities. 
Nevertheless  individuals  classed  as  neurasthenic  show  a  ten- 
dency to  inferiority  in  their  manner  of  thinking,  their  mode 
of  action,  their  ethical  feeling  and  their  freedom  of  determina- 
tion as  compared  to  persons  who  are  mentally  healthy.  All 
such  individuals  are  irritable  and  more  or  less  unable  to  con- 
trol their  desires,  emotions,  and  passions  and  therefore  they 
more  easily  become  a  menace  to  our  social  order.  As  Hoche 
very  properly  says,  many  so-called  neurasthenics  really  should 
be  classed  among  the  constitutional  inferiors.  Dubois  expresses 
himself  in  a  similar  manner  and  believes  every  neurasthenic 
to  have  a  mental  deficiency  of  some  kind. 

The  symptom  complex  that  is  developed  in  many  individuals 
and  which  has  been  designated  as  neurasthenic  may  set  in  after 
physical  or  mental  over-exertion,  sexual  or  other  excesses,  or, 
in  short,  as  a  result  of  the  enervating  influence  of  modern  cul- 


THE  NEUROPSYCHOSES  261 

tural  life.  In  all  such  instances,  however,  it  is  important  to 
remember  that  it  is  most  unusual  for  neurasthenia  to  develop 
upon  a  basis  of  mental  health.  If  in  perfect  health,  both  men- 
tally and  physically,  a  person  cannot  become  neurasthenic. 
Moreover,  in  neurasthenia  we  are  actually  dealing  with  an  af- 
fection of  the  brain,  and  therefore  it  would  be  better  to  avoid 
the  use  of  the  term  ' '  neurasthenia ' '  and  employ  in  its  stead  the 
recently  proposed  designation  ' '  psychasthenia. "  This  term  is 
more  descriptive  of  the  nature  of  the  trouble  and  aids  us  in 
our  forensic  views. 

The  neurasthenic  symptom  complex  is  made  up  in  the  main 
of  neuro-physical  manifestations,  but  these  almost  always  are 
associated  with  psychic  symptoms  which  to  a  greater  or  less  ex- 
tent dominate  the  individual's  mental  activity. 

The  essential  disturbances  in  the  neuro-physical  domain  are: 

(1)  Motor  Symptoms.  Tremor,  clonus  of  the  eyelids,  sway- 
ing of  the  body  when  the  eyes  are  closed,  unsteady,  hesitating 
speech,  slight  incoordination  of  the  muscles  and  general  mus- 
cular weakness. 

(2)  Sensory  Symptoms.  Parassthesias,  sensations  of  crawl- 
ing and  creeping,  as  well  as  pains  of  vague  nature,  occurring 
mostly  in  circumscribed  parts  of  the  body.  In  addition,  head- 
aches in  all  possible  forms  recurring  regularly,  also  migraine, 
head  pressure,  slight  spells  of  dizziness,  nickering  before  the 
eyes  and  a  feeling  of  bodily  fatigue. 

(3)  Vaso-Motor  Symptoms.  Perspiration  and  flushing  upon 
the  slightest  provocation,  congestion  of  the  face,  palpitation  and 
teachycardia. 

(4)  Reflex  Symptoms.  The  reflexes  are  often  increased,  par- 
ticularly the  knee  jerks. 

In  the  psychic  domain  we  note  above  all  a  morbid  excitability 
associated  with  a  tendency  to  rapid  exhaustion.  Neurasthenic 
persons  are  quite  capable  of  a  brief  effort,  but  cannot  concen- 
trate the  attention  for  any  extended  length  of  time.  This  in- 
stability is  accompanied  by  a  more  or  less  pronounced  difficulty 
of  comprehension  and  a  weakness  of  memory.  The  emotional 
trend  is  usually  a  pessimistic  one  and  hypochondriacal  notions 
are  frequent. 

A  symptom  of  importance  is  the  irritability  that  is  shown  by 
many  neurasthenics.     All  emotional  occurrences  upset  and  ex- 


262    THE  UNSOUND  MIND  AND  THE  LAW 

cite  them  unduly,  but  the  excitement  so  easily  produced  passes 
away  quite  as  quickly  and  is  followed  by  sorrow  and  regret 
for  what  may  have  been  said  or  done.  Characteristic  of  neu- 
rasthenia also  are  the  obsessions  that  accompany  it  (agora- 
phobia, misophobia,  etc.),  prominent  among  which  is  the  marked 
sense  of  fear  and  apprehension  that  comes  over  many  patients. 
These  obsessions  are  very  rarely  transformed  into  action.  In 
accordance  with  the  predominance  of  individual  symptoms  we 
may  speak  of  a  cerebral,  a  spinal,  a  sexual  or  some  other  form 
of  neurasthenia.  The  prognosis  under  suitable  care  and  treat- 
ment is  good. 

Forensic  Aspects 

Forensically,  neurasthenia  is  of  significance  only  in  so  far  as 
contraventions  of  minor  kind  are  concerned.  The  temporarily 
enfeebled  memory  may  entail  a  neglect  of  duty,  the  indecisive- 
ness  and  fear  may  lead  to  confusion  and  mistakes  in  the  exe- 
cution of  orders  and  the  irritability  may  lead  to  attacks  upon 
persons  and  things.  Beyond  this  the  disease  can  have  but  little 
bearing  in  criminal  or  civil  law  and  the  existence  of  the  affec- 
tion can  at  most  be  looked  upon  as  a  mitigating  factor  in  de- 
termining the  responsibility  of  the  accused  person. 

The  relationship  that  the  imperative  ideas  of  neurasthenics 
bear  to  overt  acts  they  may  commit  is  very  important.  Notions 
differ  as  to  how  these  obsessions  may  be  transformed  into  ac- 
tion. Motor  impulses  calling  for  the  commission  of  certain 
criminal  acts  are  well  known — for  instance,  the  sight  of  a 
pointed  instrument  may  arouse  the  notion  to  kill  some  beloved 
relative,  hearing  a  prominent  person  addressing  an  audience 
at  a  public  celebration  may  kindle  the  impulse  to  break  forth 
in  words  of  insult  or  derision,  the  handling  of  matches  or  a 
lighted  candle  to  set  fire  to  the  room,  etc.  As  a  matter  of  fact 
many  sexual  crimes,  incendiarism,  and  other  things  have  been 
ascribed  to  imperative  acts.  It  is  well  recognized,  however, 
that  an  assumption  of  this  kind  should  be  most  guardedly  made, 
for  not  infrequently  those  acts  are  based  upon  undiscovered 
hallucinations  and  delusions.  The  neurasthenic  patient  always 
is  able  to  view  his  imperative  thoughts  with  a  consciousness  that 
is  clear  and  unclouded,  and  consequently  is  able  to  recognize 


THE  NEUROPSYCHOSES  263 

the  unlawfulness  of  any  resultant  act  and  to  control  his  doings. 
Wheresoever  the  supposedly  imperative  acts  are  committed  we 
will  probably  always  find  some  underlying  cause  other  than 
that  of  the  imperative  impulse. 

Differential  Diagnosis 

Neurasthenic  symptoms  may  occur  in  various  diseases,  in 
severe  bodily  disorders,  tuberculosis,  exhausting  suppurative 
processes,  nephritis,  reconvalescence  after  infectious  disease  and 
especially  after  influenza.  In  organic  brain  and  spinal  cord 
diseases,  as  tabes,  tumors,  lues,  incipient  sclerosis  and  abscesses, 
we  often  encounter  such  symptoms.  This  is  true  also  of  men- 
tal diseases,  particularly  of  the  initial  stage  of  dementia  pre- 
cox and  less  frequently  of  mania,  as  well  as  of  dementia  para- 
lytica. The  differential  diagnosis  from  this  latter  disease  being 
of  the  utmost  practical  importance,  I  must  refer  to  what  has 
already  been  said  in  the  chapter  discussing  it  in  detail. 

3.   Psychic  Constitutional  Inferiority 

Hereditary  taint  manifests  itself,  as  we  have  seen,  not  only 
in  physical  signs  of  degeneration  but  also  by  the  presence  of 
certain  psychic  anomalies.  These,  in  so  far  as  they  constitute 
definite  psychoses,  do  not  concern  us  at  this  particular  mo- 
ment but  they  are  very  frequently  encountered  as  psychopathies 
of  mild  degree  which  cannot  be  classified  into  any  of  our  known 
forms  of  insanity.  Our  knowledge  of  the  anomalies  of  mental 
life  and  the  subject  of  degeneracy  is  a  product  of  modern  times 
and  has  been  best  interpreted  by  Magnan  in  France  and  Koch 
in  Germany. 

Under  the  designation  of  psychopathic  inferiority,  Koch  in- 
cludes all  the  mental  abnormalities  that  have  arisen  upon  an 
inherited  basis,  which  may  be  either  congenital  or  acquired,  and 
"which  even  in  severe  cases  do  not  represent  mental  disease 
but  even  in  the  most  favorable  cases  make  the  affected  person 
appear  as  not  in  complete  possession  of  mental  normality  and 
capability. ' ' 

This  psychopathic  inferiority,  which  was  recognized  by  the 
English  physician  Prichard  as  early  as  1825  and  termed  "moral 


264    THE  UNSOUND  MIND  AND  THE  LAW 

insanity, ' '  has  been  called  ' '  constitutional  inferiority ' '  by  Adolf 
Meyer.  So  long  as  we  recognize  the  social  import  and  the 
medico-legal  difficulties  of  its  relations,  it  is  immaterial  what 
designation  be  employed.  This  degeneracy  manifests  itself  even 
in  early  childhood.  The  affected  children  sleep  badly,  have 
night  terrors,  are  irritable  and  easily  depressed,  become  delirious 
with  slight  fever  and  have  convulsions  upon  slight  provocation. 
When  they  go  to  school  a  new  series  of  manifestations  becomes 
apparent.  Noticeable  above  all  is  an  inequality  in  their  work. 
In  some  branches  they  are  in  advance  of  their  classmates  while 
in  others  they  are  decidedly  backward.  They  are  emotional, 
excitable,  subject  to  outbursts  of  passion,  play  truant  and  are 
untruthful  and  deceitful.  Many  show  great  cruelty  to  animals 
and  disregard  for  the  sufferings  of  others.  In  school  they  are 
the  despair  of  their  teachers,  at  home  of  their  parents.  When 
they  attain  the  age  of  puberty  we  note  a  more  brusque  develop- 
ment than  is  the  case  in  the  normal  child.  The  emotional  in- 
stabilities of  early  life  become  increased.  Maladjustment  to 
their  surroundings  now  becomes  manifest.  Likes  and  dislikes 
are  most  pronounced.  The  entire  development  is  disharmonic. 
Many  such  children  show  a  prematurity  of  development,  while 
in  others  the  period  of  adolescence  is  much  more  extended  than 
In  normal  persons,  maturity  not  taking  place  until  around  the 
twenty-fifth  year.  Their  later  life  is  characterized  by  a  dimin- 
ished tolerance  toward  atmospheric  and  temperature  changes, 
by  an  emotional  disequilibrium  of  the  most  pronounced  kind, 
by  an  abnormal  exhaustibility  manifesting  itself  in  rapid 
fatigue,  by  slowness  of  thought  and  weakness  of  will.  This 
lack  of  balance,  so  characteristic  of  degeneracy,  may  be  par- 
ticularly manifest  at  certain  periods  of  the  individual's  life 
and  then  we  often  find  special  inclinations  and  impulses  pres- 
ent at  a  time  that  must  be  considered  premature.  This  is  shown 
in  some  such  individuals  by  the  abnormally  early  development 
of  the  sexual  desires  and  sexual  potency  and  the  sexual  trend 
given  to  their  entire  thought.  The  chapter  on  sexual  perversion 
will  show  the  bearing  this  may  have  upon  their  subsequent  life. 
The  adult  psychopath  manifests  to  a  yet  more  pronounced 
degree  the  traits  already  mentioned,  more  especially  the  lack  of 
emotional  balance  and  the  intellectual  inequalities.  The  men- 
tal anomalies  of  adults  may  be  divided  into  those  of  the  in- 


THE  NEUROPSYCHOSES  265 

tellect,  those  of  the  emotions  and  those  of  the  will.  From  a  so- 
cial standpoint  those  of  the  intellect  are  the  most  important. 
The  attention  is  weak,  the  memory  feeble,  the  association  of 
ideas  sluggish  and  the  imagination  limited.  A  pronounced  fea- 
ture is  the  intense  egotism.  Immeasurable  vanity,  grandiose 
ideas  and  notions  of  reference  are  fundamental.  These  psy- 
chopaths are  unbounded  in  the  demands  they  make  for  them- 
selves and  are  totally  regardless  of  other  persons'  rights.  They 
are  most  appreciative  of  their  own  accomplishments  and  depre- 
ciatingly critical  of  the  deeds  of  others.  The  intellectual  an- 
omalies bring  forth  a  type  that  embraces  a  wide  range  of  in- 
feriority which  may  differ  in  both  character  and  quality. 
Idiocy,  imbecility  and  moronism  constitute  one  end  of  the  chain 
while  at  the  other  we  find  but  a  relative  intellectual  deficiency 
which  causes  no  social  disturbance  because  it  is  offset  by  a  fairly 
good  development  of  the  emotional  and  volitional  faculties. 

The  emotional  form  of  constitutional  inferiority  also  pre- 
sents well  defined  characteristics.  Usually  there  is  an  extreme 
mobility  of  moods;  in  some  instances  there  is  a  deficiency  or 
excess  of  emotional  activity.  Some  are  over-sensitive,  secretive 
and — as  Hoch  expresses  it — "shut  in,"  others  are  vivacious,  lo- 
quacious and  lacking  in  restraint.  The  conduct  is  the  result 
of  the  inadequacy  of  judgment  and  the  instability  of  the  emo- 
tions. It  is  full  of  contradictions.  In  the  life  of  such  inferiors 
changes  of  situations  and  occupations  are  of  frequent  occur- 
rences, differences  and  quarrels  with  associates  and  superiors 
are  common.  Everything  they  undertake  is  a  failure  and  fateful 
injustice  is  blamed  for  all.  Thus  we  see  in  the  constitutional 
inferior  a  person  who  is  characterized  by  a  disequilibrium  of 
intellect,  emotion,  conduct  and  efficiency.  He  is  not  insane  in 
the  restricted  sense  of  the  word  except  when  episodically  some 
extraordinary  occurrence  such  as  an  arrest,  an  unfortunate  love 
affair,  or  the  loss  of  money,  etc.,  produces  a  passing  depressive 
or  manic  psychosis.  As  a  rule  constitutional  inferiors  occupy 
the  borderline  between  mental  health  and  mental  disease.  For 
this  reason  proof  of  the  existence  of  any  or  many  manifesta- 
tions of  constitutional  inferiority  does  not  carry  with  it  proof 
of  the  individual 's  insanity.  For  this  more  is  needed.  To  what 
extent  the  existing  inferiority  will  exert  an  influence  upon  the 
person's  free  determination  must  be  decided  in  each  individual 


266    THE  UNSOUND  MIND  AND  THE  LAW 

instance.  The  difficulties  in  arriving  at  such  a  decision  are  the 
same  as  in  all  borderline  conditions.  The  clinical  varieties  of 
the  volitional  form  of  constitutional  inferiority  are  many  and 
in  some  instances  they  remain  undetected  until  they  come  into 
conflict  with  the  law.  By  far  the  greater  number  of  cases 
of  constitutional  inferiority,  as  Ziehen  has  pointed  out,  present 
distinct  bodily  abnormalities  as  well.  Upon  the  somatic  side  we 
find  a  poor  general  development,  dwarfish  growth,  infantilism, 
irregularity  in  the  development  of  certain  parts  and  the  various 
so-called  stigmata  of  degeneracy  spoken  of  in  an  earlier  chapter. 
Tremor,  facial  and  other  tics,  nystagmoid  movements  of  the 
eyeballs,  headaches  and  nocturnal  enuresis  occurring  into  an 
advanced  age  are  most  frequent. 

Forensic  Aspects 

The  anti-social  acts  of  such  constitutional  inferiors  are  of  the 
most  varied  kind,  those  most  frequently  met  with  being,  in  the 
order  mentioned,  fraud,  burglary,  sexual  crimes,  highway  rob- 
bery and  personal  injur/. 

Just  how  these  constitutional  inferiors,  who  certainly  are  but 
restrictedly  responsible,  should  be  treated  by  the  law  is  rather 
a  technical  legal  question  than  a  medical  one.  They  are  often 
so  incapable  of  social  self-control  under  the  ordinary  demands 
of  life  that  they  must  be  safeguarded,  yet  they  are  so  much 
on  the  borderline  that  they  belong  neither  in  institutions  for 
the  feeble-minded  nor  in  asylums  for  the  insane,  and  still  they 
should  not  be  punished  by  internment  in  a  penal  institution. 
The  establishment  of  special  institutions,  where  they  can  be 
kept  for  a  prolonged  period  of  time,  at  all  events  until  they 
are  no  longer  a  menace  to  the  public,  seems  to  be  an  urgent 
need.  In  such  institutions  they  would  receive  the  medical 
treatment  called  for  by  modern  research  work  relating  to  the 
influence  of  the  ductless  glands  in  the  production  of  disease. 

4.     Epilepsy 

Epilepsy  is  a  disease  of  the  brain  usually  implanted  upon 
a  soil  that  has  a  marked  hereditary  taint.  It  is  characterized 
by  the  periodical  occurrence  of  disorders  of  consciousness.    We 


THE  NEUROPSYCHOSES  267 

distinguish  between  typical  epilepsy  and  concealed  or  larvated 
epilepsy.  The  designation  "typical  epilepsy"  is  applied  to  all 
those  cases  that  have  attacks  of  epileptic  convulsions  or  dizzi- 
ness. In  concealed  (larvated)  epilepsy,  the  characteristic  at- 
tacks are  usually  absent ;  moreover,  the  epileptic  symptoms  are 
of  a  psychic  nature,  while  attacks  with  abolition  of  conscious- 
ness are  exceptional  or  occur  only  in  a  rudimentary  form. 
Hence  the  characteristic  trait  of  larvated  epilepsy  is  the  psychic 
equivalent. 

In  typical  epilepsy  the  main  symptom  is  recognized  by  the 
convulsive  attacks,  which  may  be  divided  into  rudimentary, 
small  and  large  ones.  The  rudimentary  attacks  are  simple  faint- 
ing spells  without  convulsions  but  with  complete  loss  of  con- 
sciousness and  subsequent  amnesia.  They  are  also  designated 
as  "absences."  Among  rudimentary  attacks,  however,  we  also 
include  spells  of  dizziness  that  pass  by  rapidly  and  in  which 
consciousness  is  not  entirely  lost,  so  the  victim  still  has  time 
to  guard  himself  against  falling.  In  addition  there  are  abnor- 
mal psychic  states  made  up  of  spells  in  which  the  patient  has 
the  sensation  of  having  once  before  lived  through  exactly  the 
same  experience  in  precisely  the  same  manner.  This  state  is 
known  as  paramnesia.  Sometimes,  too,  the  patient  suddenly 
becomes  overpowered  by  fear  and  indefinite  despair,  during 
which  he  has  a  feeling  as  though  he  no  longer  exists  or  has 
faded  into  thin  air.  After  an  attack  of  this  kind  the  patient 
believes  he  has  actually  passed  through  an  experience  so  ex- 
traordinary that  it  is  entirely  indescribable. 

The  small  epileptic  attacks  (epilepsia  minor)  are  typical 
spells  imperfectly  developed.  The  patient  suddenly  loses  con- 
sciousness and  sinks  to  the  ground;  then  a  short  tonic  convul- 
sion sets  in  and  the  return  to  consciousness  follows  without  any 
intermediary  clonic  phase. 

The  large  epileptic  attacks  may  be  divided  into  four  phases, 
as  follows: 

(1)  The  Phase  of  Prodromata.  Many  epileptics  feel  an  at- 
tack coming  minutes  or  hours  before  it  actually  occurs.  Before 
the  outbreak  a  certain  definite  warning  signal  appears  to  them, 
and  this  always  occurs  in  precisely  the  same  manner  in  the 
same  epileptic.  This  is  called  the  aura  and  may  be  of  niotor, 
sensory,  vaso-motor  or  psychic  nature  or  may  affect  one  of  the 


268    THE  UNSOUND  MIND  AND  THE  LAW 

special  senses.  The  motor  aura  consists  of  isolated  clonic  and 
tonic  twitchings  in  the  distribution  of  some  motor  nerve,  as 
in  the  thumb  or  in  the  face;  the  sensory  aura  is  characterized 
by  a  sudden  pain,  headaches  or  paresthesias,  and  especially 
by  a  sensation  as  of  the  passing  of  a  cool  current  of  air  (hence 
the  name  aura)  ;  the  vaso-motor  aura  is  made  up  of  general  or 
localized  sweating  with  palpitation;  the  psychic  aura  consists 
of  a  feeling  of  fear,  paramnesia  and  the  dreamy  state  (sensa- 
tion of  fading  into  nothingness)  already  described,  while  the 
aura  of  special  sense  consists  of  hallucinations  in  any  or  all 
of  the  specific  nerve  domains.  The  epileptic  having  an  aura 
knows  an  attack  is  imminent  and  makes  provisions  to  protect 
himself  against  a  fall.  But  in  many  epileptics  the  aura  is 
absent.  In  their  cases  the  convulsions  set  in  while  conscious- 
ness is  intact;  they  fall  to  the  ground  and  often  injure  them- 
selves materially. 

(2)  The  Phase  of  Tonic  Spasm.  The  patient  suddenly  be- 
comes pale,  gives  a  rending  cry  and  falls  unconscious  to  the 
ground.  Some  fall  upon  the  back,  others  upon  the  side,  the 
majority  upon  the  face.  At  once  a  general  stiffness  of  the  body 
sets  in,  the  eyes  are  turned  upward,  the  head  is  twisted  to  one 
side,  the  mouth  is  distorted,  the  thumb  is  flexed  within  the 
closed  hand,  the  convulsive  distorted  face  becomes  livid,  respira- 
tion having  come  almost  to  a  standstill  as  a  result  of  spasm  of 
the  diaphragm,  and  the  pupils  are  widely  dilated  and  reaction- 
less,  or  respond  slightly  to  light.  Semen  may  be  ejaculated  and 
an  evacuation  of  urine  and  feces  may  occur.  The  pulse  is 
hard  and  rapid. 

(3)  The  Phase  of  Clonic  Spasm.  After  a  few  seconds  of  tonic 
spasm  the  jerkings  begin,  first  slowly,  then  rapidly  increasing 
in  frequency.  The  head  is  jerked  from  one  side  to  the  other, 
the  angles  of  the  mouth  are  drawn  sideways  as  far  as  possible, 
the  tongue  is  thrown  from  and  drawn  back  into  the  mouth  and 
is  injured  by  the  teeth,  blood  and  bloody  saliva  are  emitted 
from  the  mouth,  and  the  face,  which  until  this  time  has  been 
contortionately  fixed,  becomes  constantly  altered  in  consequence 
of  the  muscular  jerkings  and  the  rolling  of  the  eyeballs.  The 
jerkings  implicate  the  entire  musculature  of  the  body.  Respira- 
tion is  often  reduced  in  frequency  and  the  body  temperature 
rises  by  several  tenths  of  a  degree. 


THE  NEUROPSYCHOSES  269 

(4)  The  Phase  of  Stertorous  Sleep.  Gradually  the  jerkings 
cease  and  the  phase  of  stertorous  sleep  begins  with  a  deep  loud 
inspiration;  the  relaxed  limbs  fall  to  the  ground,  the  forehead 
becomes  covered  with  a  profuse  sweat,  the  patient  lies  in  a  deep 
coma  and  the  loud  stertorous  breathing  sets  in.  The  sleep  lasts 
from  one  quarter  of  an  hour  to  two  hours  and  sometimes  even 
longer.  Then  the  patient  awakens,  usually  with  a  headache 
and  a  sensation  of  pronounced  fatigue.  Amnesia  for  the  time 
covering  the  attack  exists ;  less  frequently  there  is  a  retrograde 
amnesia.  By  the  headache,  by  the  injury  to  the  tongue  or  from 
statements  made  by  witnesses,  the  patient  knows  an  attack  has 
taken  place.  In  some  epileptics  the  attacks  occur  only  at  night 
(epilepsia  nocturna)  ;  in  a  few  cases  the  patients  run  a  distance 
before  they  fall.  Some  patients  have  a  periodic  migraine,  others 
in  addition  to  the  large  attacks  have  isolated  spasms  of  the 
diaphragm  and  unconsciousness  (respiratory  epilepsy). 

Attacks  accompanied  by  loss  of  consciousness  are  also  en- 
countered. These  are  made  up  of  transitory  paralyses  of  the 
extremities,  a  sudden  general  muscular  weakness  with  falling 
as  well  as  brief  isolated  jerkings  in  individual  muscular  terri- 
tories, such  as  the  eye  muscles,  facial  muscles,  etc. 

The  psychic  disorders  that  occur  in  epileptics  are  of  the  most 
manifold  nature.     Most  frequently  we  find: 

(1)  Dreamy  States  with  Slight  Disorder  of  Consciousness 
and  Impulsive  Actions.  The  latter  are  characterized  by  the 
sudden  onset  of  the  impulse  and  an  uncontrollable  desire  to 
carry  it  into  execution.  Many  dangerous  acts,  such  as  murder, 
incendiarism,  etc.,  are  committed  by  epileptics.  Other  epilep- 
tics have  attacks  of  an  automatic  wandering  impulse  (porio- 
mania), in  consequence  of  which  they  often  wander  about  aim- 
lessly for  hours  and  days.  Many  instances  of  desertion  be- 
long to  this  category. 

(2)  States  of  Depression  with  Retained  Consciousness.  Such 
epileptic  depression  is  characterized  by  the  existence  of  a  pro- 
nounced irritability  and  an  explosive  affect  which  not  infre- 
quently is  produced  by  the  slightest  cause  and  may  lead  to  the 
most  horrible  acts  of  violence.  The  patients  are  moody,  give 
vent  to  hypochondriacal  and  self-accusatory  ideas  and  often  at- 
tempt suicide.    These  states  usually  pass  by  rapidly. 


270    THE  UNSOUND  MIND  AND  THE  LAW 

(3)  Transient  States  Accompanied  by  a  More  or  Less  Deep 
Obscuration  of  Consciousness.  These  are  designated  as  twi- 
light states  and  may  precede  or  follow  the  convulsive  attack 
(pre-  and  post-epileptic  insanity)  or  may  occur  without  any 
relation  to  the  attack  itself.  They  constitute  the  psychic 
equivalent  that  has  already  been  mentioned.  The  severe  epi- 
leptic mental  disorders  are  mostly  post-epileptic,  setting  in 
after  a  severe  convulsive  attack  or  after  a  series  of  attacks,  but 
they  also  occur  in  the  form  of  a  psychic  epileptic  equivalent. 
The  epileptic  twilight  states  manifest  themselves  under  so 
many  different  forms  that  it  is  impossible  to  classify  them 
specially.  They  all,  however,  have  certain  common  traits 
which  are  present  to  a  greater  or  less  extent  in  the  individual 
attacks.    These  are : 

(a)  The  onset  is  acute  and  is  at  once  present  in  its  full  in- 
tensity. 

(b)  The  chief  symptom  is  a  more  or  less  marked  cloudedness 
of  consciousness  in  consequence  of  which  the  patients  usually 
are  disoriented,  misconstrue  their  surroundings  and  distort  or 
do  not  at  all  perceive  impressions  from  without. 

(c)  The  cloudedness  of  consciousness  is  usually  variable  in 
intensity  and  extent.  In  one  instance  there  may  exist  complete 
confusion  with  great  restlessness,  speech  disorders,  disturbances 
of  motility,  states  of  fear,  inhibition  of  thought  and  sensory 
hallucinations  of  a  threatening  kind  (apprehensive  delirium)  ; 
in  another  instance  there  will  be  a  slight  obscuration  of  con- 
sciousness accompanied  by  a  joyous  hypomanic  excitement  and 
distinct  incoherence  of  thought  processes ;  then  again  there  may 
occur  a  deep  stupor  with  mutism,  automatic  movements  and 
catalepsy,  or  a  phase  of  religious  ecstasy;  or  again  a  phase  of 
relative  lucidity  may  set  in  during  which  the  patient  seems  to 
be  entirely  clear,  answers  specific  questions  correctly,  yet  com- 
mits the  most  nonsensical  acts. 

(d)  Sensory  deceptions  of  all  kinds  as  they  occur  in  typical 
epilepsy  accompany  the  twilight  states.  They  recur  with  uni- 
formity in  all  epileptics. 

(e)  Paranoid  and  expansive  religious  ideas  of  a  vague  na- 
ture are  frequent. 

(f)  The  impulsive  and  often  dangerous  acts  of  epileptics  rep- 
resent a  reaction  to  the  appalling  sense  deceptions  or  are  the 


THE  NEUROPSYCHOSES  271 

consequence  of  states  of  fear,  or  an  inimical  illusionary  distorted 
view  of  the  surrounding  world. 

(g)  The  facial  expression  usually  reflects  the  obscuration  that 
exists  to  a  greater  or  less  extent.  The  eyes  are  staring  and 
wander  about  inattentively;  the  states  of  religious  ecstasy  are 
revealed  by  the  facial  expression. 

(h)  Manifestations  of  motor  excitement,  tremor  of  the  hands, 
of  the  tongue,  of  the  eyelids,  slight  ataxia,  swaying  with  closed 
eyes,  pupilary  differences  and  increased  reflexes  may  be  demon- 
strated during  the  twilight  states. 

(i)  After  the  attack  amnesia  usually  exists.  This  may  be 
of  various  degrees  of  intensity. 

In  the  majority  of  epileptics  there  is  usually  developed  a 
permanent  abnormal  state  which  may  be  designated  briefly  as 
the  epileptic  temperament.  It  is  much  more  sharply  defined 
than  the  hysterical  temperament  and  recurs  with  the  greatest 
monotony  and  in  many  epileptics,  with  a  repetition  of  every 
small  detail.  Epileptics  are  usually  irritable,  sensitive  and 
burst  into  paroxysms  of  anger  and  rage  upon  the  slightest  prov- 
ocation. Their  actions  and  conduct  are  generally  characterized 
by  a  monotonous  pedantry;  they  are  excessively  polite,  often 
pronouncedly  servile,  tend  toward  digressions  in  speech,  making 
use  of  high  sounding  words,  stereotyped  phrases  and  not  infre- 
quently of  word  distortions.  Often  they  manifest  an  osten- 
tatious religiosity.  Hysterical  traits  are  frequently  present 
but  usually  the  epileptic  becomes  entirely  dominated  by  egoistic 
ideas,  while  those  of  an  altruistic  nature  are  gradually  lost. 
Withal  they  are  pharisaically  just  towards  themselves  and  ex- 
aggeratedly self-satisfied.  The  increasing  feeble-mindedness 
narrows  their  views  more  and  more,  the  scope  of  their  associa- 
tion processes  becomes  more  and  more  restricted  and  little  by 
little  their  own  ego  plainly  comes  into  the  foreground  of  their 
every  thought  and  act.  The  frequency  of  the  attacks  varies 
widely  in  different  patients.  Some  epileptics  have  convulsions 
but  once  a  year  or  even  at  longer  intervals,  while  others  have 
them  so  frequently  that  for  days  they  pass  directly  from  one 
spell  into  another. 

In  so  far  as  the  prognosis  of  epilepsy  is  concerned,  we  must 
for  practical  purposes  differentiate  between  epilepsy  occurring 
early  and  that  which  occurs  late  in  life.    Early  epilepsy  is  most 


272    THE  UNSOUND  MIND  AND  THE  LAW 

frequent  and  begins  before  the  twentieth  year.  It  leads  to  feeble- 
mindedness and  idiocy.  Late  epilepsy  either  leaves  the  intel- 
ligence essentially  intact  or  it  leads  to  moral  feeble-mindedness 
and  the  development  of  the  epileptic  temperament.  Only  about 
six  or  eight  per  cent  of  epileptics  recover.  Otherwise  the  prog- 
nosis of  epilepsy  may  be  embodied  in  the  following  statements: 

(1)  The  later  in  life  the  attacks  set  in  and  the  more  infre- 
quently they  occur,  the  better  will  be  the  prognosis. 

(2)  The  more  variable  the  attacks  (large  attacks,  dizziness, 
absences),  the  worse  will  be  the  prognosis. 

(3)  The  epileptic  attacks  of  vertigo  usually  lead  to  dementia 
more  rapidly  than  do  the  large  attacks. 

(4)  The  epileptic  twilight  states  generally  pass  away  without 
causing  deeper  injury,  but  they  have  a  tendency  to  recur  and 
then  gradually  lead  to  dementia. 

Differential  Diagnosis 

The  term  ' c  epilepsy, ' '  as  used  here,  applies  only  to  those  cases 
in  which  the  existence  of  an  organic  lesion  or  of  an  intoxica- 
tion may  be  excluded,  for  typical  epileptic  convulsive  attacks 
with  amnesia  are  also  encountered  in  the  following: 

(1)  In  organic  lesions  of  the  brain  such  as  arterial  disturb- 
ances, brain  tumors,  brain  abscesses  (cortical  convulsions). 

(2)  In  systemic  intoxication  (alcohol,  lead,  acetone  and 
uraemia) . 

Only  after  these  causes  have  been  excluded  can  the  diagnosis 
of  genuine  epilepsy  be  made.  The  older  the  individual  at  the 
time  of  the  outbreak  of  the  epilepsy  the  less  probable  will  be 
the  existence  of  a  genuine  epilepsy.  More  often  epilepsy  will 
be  confounded  with  hysteria.  The  differential  diagnosis  be- 
tween hysteria  and  epilepsy  must  always  be  distinct  and  precise. 
A  hystero-epilepsy,  referred  to  by  some  authors,  does  not  exist. 
In  such  instances  mentioned  by  them,  we  are  usually  dealing 
with  true  epileptics  having  hysterical  traits.  Of  prime  impor- 
tance for  a  differential  diagnosis  is  the  determination  of  the 
question  whether  the  temperament  is  an  hysterical  or  an  epi- 
leptic one.  Typical  epileptic  attacks  differ  from  hysterical 
ones  by  the  following  symptoms. 

In  hysteria  the  aura  is  infrequent,  in  epilepsy  frequent;  in 


THE  NEUROPSYCHOSES  273 

hysteria  the  attacks  begin  after  psychic  excitement,  while  in 
epilepsy  they  set  in  independently  of  external  causes;  in  epi- 
lepsy the  attack  is  inaugurated  by  a  scream,  but  as  a  rule  this 
does  not  occur  in  hysteria;  in  epilepsy  there  exists  marked 
vascular  disturbance  accompanied  by  a  deathlike  pallor,  but  in 
hysteria  the  vascular  spasm  is  wanting  or  can  be  but  faintly 
recognized;  epileptic  patients  suddenly  fall  to  the  ground  and 
often  injure  themselves  severely,  but  hysterics  slide  down 
or  fall  with  care  and  receive  no  injury ;  in  epilepsy  we  encounter 
asphyxia  and  cyanotic  discoloration  of  the  face,  but  not  in 
hysteria;  in  epilepsy  reflex  rigidity  of  the  pupils  or  sluggishly 
reacting  pupils  are  the  rule,  in  hysteria  the  exception;  in  epi- 
lepsy there  is  tongue  biting,  but  not  in  hysteria ;  in  epilepsy  we 
encounter  involuntary  evacuations,  in  hysteria  these  are  infre- 
quent; in  epilepsy  "arc  de  cercle"  is  very  rarely  present,  while 
in  hysteria  it  always  exists;  in  epilepsy  the  convulsive  attacks 
consist  of  simple  clonic  jerkings,  but  in  hysteria  the  convulsive 
movements  are  extraordinarily  diverse;  in  epilepsy  the  patient 
lies  in  coma  breathing  stertorously,  in  hysteria  the  coma  is 
absent  and  the  breathing  is  abnormal;  in  epilepsy  the  attacks 
last  from  one  to  one  and  one-half  minutes,  in  hysteria  from  a 
quarter  to  a  half  an  hour  and  longer;  finally  in  epilepsy  there 
is  complete  loss  of  consciousness  during  the  attacks,  while  in 
hysteria  there  is  at  most  a  slight  cloudiness  of  consciousness 
toward  the  end  of  the  attack. 

The  states  of  depression  of  an  epileptic  nature  differ  from 
other  states  of  depression  by  the  presence  of  transitory  dis- 
turbances of  consciousness,  motor  manifestations,  typical  sense 
deceptions  and  paranoid  delusions.  Disorientation,  the  peculiar 
facial  expression,  abnormalities  of  the  skull  as  found  in  epi- 
lepsy (hydrocephaly),  maximally  dilated  pupils  and  other 
symptoms  may  aid  in  arriving  at  a  diagnosis.  Epileptic  twi- 
light states  will  transitorily  manifest  a  manic  or  paranoid  color- 
ation, but  they  can  hardly  be  confounded  with  manic  or 
paranoiac  states. 

Forensic  Aspects 

The  offenses  against  the  law  committed  by  epileptics  may  be 
deduced  from  the  foregoing  description.    The  emotional  insta- 


274    THE  UNSOUND  MIND  AND  THE  LAW 

bility,  the  tendency  to  outbursts  of  passion,  will  easily  bring 
about  breach  of  the  peace,  injury  to  property  and  attacks  upon 
persons.  The  degeneration  that  sets  in  in  many  instances,  and 
which  is  so  often  associated  with  the  moral  and  intellectual  de- 
fects dependent  upon  an  abuse  of  alcohol,  makes  of  these  epi- 
leptics tramps,  habitual  thieves,  prostitutes  and  suborners  of 
prostitution.  The  legal  contraventions  of  epileptics  in  the 
order  of  their  frequency,  according  to  Huebner,  are  forgery, 
fraud,  attacks  against  persons  and  sexual  crimes. 

Of  importance  for  the  forensic  estimation  of  all  these  cases 
is  the  fact  that  the  epileptic  is  not  insane  because  he  is  an  epi- 
leptic, but  he  is  always  upon  the  boundary  between  sanity  and 
insanity  and  may  at  any  moment  pass  over  the  line.  There 
are  epileptics  who  throughout  their  lives  have  but  occasional 
convulsive  attacks  and  never  any  transitory  losses  of  conscious- 
ness except  those  connected  with  these  attacks,  and  whose  re- 
sponsibility outside  of  the  period  immediately  preceding  or  im- 
mediately following  or  during  the  attack  cannot  be  questioned. 
Of  others  there  are  all  kinds,  all  transitions,  leading  to  the  de- 
teriorated and  feeble-minded  ones  who  are  always  and  under  all 
circumstances  irresponsible.  The  fact,  however,  that  even  those 
in  the  category  first  mentioned  do  have  periods  when  their 
consciousness  is  disordered  and  in  which  they  are  irresponsible 
makes  it  imperative  to  examine  every  epileptic  specially  with 
this  in  mind. 

The  twilight  states  of  epilepsy  are  of  the  greatest  forensic 
importance,  particularly  because  the  patients  while  in  such  a 
state  need  not  appear  to  be  in  any  way  abnormal.  Neither  by 
their  facial  expression,  their  gait  nor  their  conduct  need  they 
attract  attention  and  yet  there  exists  a  condition  in  which  con- 
sciousness is  more  or  less  obscured. 

In  the  majority  of  instances,  however,  the  disordered  state 
may  be  recognized  by  the  vague  expressionless  physiognomy, 
the  unsteadiness  of  gait  and  speech  and  above  all  by  the  inequal- 
ity of  the  psychic  efficiency  of  such  patients,  who  at  one  time 
give  perfectly  responsible  replies  and  a  few  seconds  later  will 
answer  the  same  questions  incorrectly  and  distractedly. 


THE  NEUROPSYCHOSES  275 

5.    Chorea 

Chorea  minor  (Sydenham's  chorea)  is  often  accompanied  by- 
psychic  anomalies,  and  sometimes  by  actual  psychoses.  The  ma- 
jority of  chronic  patients  show  a  more  or  less  marked  excita- 
bility, decided  mental  instability  and  an  inability  to  concen- 
trate the  attention.  They  are  prone  to  mental  agitation,  are 
difficult  to  please,  tend  to  extreme  emotional  outbreaks  and 
sometimes  develop  all  kinds  of  anti-social  traits  that  are  remind- 
ful of  hysteria  (chronic  emotional  degeneration).  Not  infre- 
quently we  find  in  them  a  diminution  of  mental  alertness,  weak- 
ness of  memory,  and  a  certain  intellectual  inefficiency  occasion- 
ally accompanied  by  a  peculiar  foolish,  incongruous  behavior 
(choreic  degeneration).  In  many  choreics  the  psychic  obtuse- 
ness  is  shown,  if  by  nothing  else,  by  the  slight  influence  the 
disease  seems  to  have  upon  their  sense  of  appreciation  of  their 
own  illness. 

Actual  psychoses  are  comparatively  infrequent  in  chorea. 
Manic  states  of  excitement  with  marked  incoherence  of  thought 
and  appalling  visions,  delirious  states  with  similar  illusions  and 
ideas  of  persecution,  as  well  as  states  of  depression,  are  occa- 
sionally encountered. 

Often  the  psychic  disorders  disappear  when  the  chorea  has 
been  cured.  The  prognosis  of  most  of  the  mental  disorders 
that  occur  in  chorea  minor  is  favorable.  Some,  however,  end 
fatally,  particularly  the  delirious  forms. 

In  Huntington's  chorea  (chorea  chronica  progressiva)  we 
also  encounter  anomalies  of  character  and  mental  disturbances. 
This  affection  often  ends  in  dementia.  The  prognosis  is  bad, 
both  as  regards  the  chorea  and  the  accompanying  psychosis. 

Differential  Diagnosis 

The  diagnosis  of  chorea  is  easy.  In  all  cases,  but  more  par- 
ticularly in  those  of  hemi-chorea,  the  existence  of  some  organic 
disease  of  the  brain  must  be  considered. 

Certain  cases  of  hysteria  may  cause  difficulty  in  diagnosis. 
In  these  our  opinion  will  sometimes  be  determined  by  the  anam- 
nesis (rheumatism  in  chorea)  as  well  as  the  existence  of  car- 
diac involvement   (mitral  insufficiency)   and  the  peculiar  state 


276    THE  UNSOUND  MIND  AND  THE  LAW 

of  the  patellar  reflexes  that  is  often  found  in  chorea.  The  re- 
flex peculiarity  just  referred  to  consists  in  a  hypertonicity,  the 
lower  leg  remaining  for  a  short  time  in  a  posture  of  extension 
after  the  patellar  tendon  has  been  struck  and  then  sinking 
gradually  back  into  a  pendant  position.  Of  further  value  in 
arriving  at  a  definite  diagnosis  will  be  the  dull,  silly  tempera- 
ment of  the  choreic  patient  as  contrasted  with  the  stigmata 
and  the  mobile  temperament  of  the  hysteric.  The  forensic 
significance  of  the  choreic  states  should  not  give  rise  to  dif- 
^culties. 


Ill 

THE  PSYCHOSES  OF  INVOLUTION 

1.    Dementia  Senilis 

Dementia  Senilis  is  a  progressive  disorder  that  leads  to  men- 
tal decay,  arises  around  the  sixtieth  year  of  life  and  is  accom- 
panied by  the  physical  signs  of  senility.  In  a  comparatively 
few  cases  the  psychosis  begins  before  the  sixtieth  year  (demen- 
tia senilis  prascox).  Like  dementia  paralytica  this  affection 
is  Protean  in  its  course  and  may  develop  under  the  guise  of  a 
simple  progressive  dementia  or  under  that  of  a  manic,  melan- 
cholic, paranoiac  or  other  picture  of  disease. 

The  course  of  senile  dementia  may  be  divided  into  three 
stages: — the  initial  stage,  that  of  marked  dementia,  and  the 
terminal  stage. 

(1)  The  initial  stage  may  be  represented  by  very  different 
conditions,  the  most  frequent  of  which  are  the  following: 

(a)  The  psychosis  begins  insidiously.  This  is  usually  the 
case.  Gradually  a  slight  diminution  of  the  entire  psychic  ef- 
ficiency becomes  noticeable;  the  patients  become  less  impres- 
sionable and  less  accessible  to  new  ideas,  their  memory  becomes 
weaker  and  they  are  easily  fatigued.  Bit  by  bit  an  alteration 
in  character  sets  in;  some  patients  become  querulous,  irritable 
and  egoistic,  while  others  become  lachrymose,  lose  their  self- 
control,  get  excited  about  every  trifle  and  like  children  become 
obstinate  and  angry  whenever  their  will  is  opposed.  Morally 
also  the  decadence  is  manifest;  the  patients  become  indecent, 
lascivious  and  not  infrequently  commit  offenses  against  public 
decency.  Immoral  behavior  with  children  and  exhibitionism 
are,  so  to  say,  typical  of  senile  dementia.  Drunkenness  in  some 
eases  and  intolerance  to  alcohol  in  others  are  also  common  ini- 
tial symptoms  of  senile  dementia. 

(b)  In  other  instances,  and  these  are  not  infrequent,  demen- 

277 


278    THE  UNSOUND  MIND  AND  THE  LAW 

tia  sets  in  with  a  marked  state  of  depression,  often  remindful 
of  melancholia.  A  deep  sorrowful  mood,  ideas  of  sinfulness, 
fears  and  hallucinations  of  hearing  may  be  present. 

(c)  The  beginning  is  often  associated  with  a  mild  depression 
and  numerous  hypochondriacal  complaints  and  illusions. 

(d)  In  certain  instances  senile  dementia  begins  with  a  pro- 
nounced paranoiac  symptom  complex.  The  patients  become 
depressively  suspicious  and  reserved.  They  express  notions  of 
persecution  and  believe  they  have  been  robbed  or  poisoned  and 
that  their  lives  are  to  be  endangered.  Sense  deceptions  almost 
always  accompany  the  delusions. 

(e)  The  psychosis  may  also  begin  under  the  guise  of  a  hypo- 
manic  state  of  excitement,  but  this  is  less  frequent. 

All  these  varied  initial  states  of  senile  dementia  receive  their 
special  impress  from  the  senile  mental  enfeeblement  that  sooner 
or  later  becomes  noticeable.  This  is  characterized  in  particu- 
lar by  the  marked  disorder  of  memory  for  recent  events,  fre- 
quently associated  with  a  pronounced  tendency  to  confabula- 
tions, while  the  old  memory  store  often  remains  unaffected  for 
an  astonishingly  long  time.  Equally  striking  are  the  emotional 
disturbances  which,  according  to  the  existing  psychic  state, 
constitute  a  foolish,  childish  euphoria,  a  stupid  apathy,  an  ex- 
alted irritability  or  a  deep  melancholia.  Finally  we  will  note 
a  lack  of  judgment  that  manifests  itself  in  absurd,  uncritical 
delusions,  feebleness  of  will  power  and  an  abatement  of  the 
finer  ethical  perceptions. 

(2)  The  initial  phase  may  continue  for  a  long  or  a 
short  period  and  then  the  stage  of  well  defined  dementia  is 
reached.  The  memory  for  recent  events  becomes  entirely  ex- 
tinguished and  the  memory  for  the  distant  past  dwindles  more 
and  more.  The  conceptual  and  expressional  store  becomes  more 
and  more  restricted ;  the  patient  forgets  his  own  age  and  the 
year  of  his  birth  and  becomes  permanently  disoriented  both  as 
to  time  and  place.  Some  patients  may,  notwithstanding  their 
decided  dementia,  preserve  a  comportment  that  is  outwardly 
correct ;  their  association  with  those  about  them  is  faultless, 
their  manner  of  living  is  a  regular  one,  they  read  their  papers, 
play  cards  and  act  like  any  perfectly  normal  old  person ;  still 
their  judgment  is  untrustworthy,  they  are  disoriented  and  have 
no  power  of  determination.    As  compared  with  simple  dementia, 


THE  PSYCHOSES  OF  INVOLUTION        279 

pronounced  disorders  are  much  more  frequent,  and  these  may 
be  summarized  as  follows : 

(a)  In  very  many  senile  dements  there  exists  a  noticeable 
difference  between  the  conduct  during  the  day  and  the  conduct 
during  the  night.  In  the  daytime  they  are  quiet,  fairly  well 
oriented  and  somnolent,  but  at  night  they  become  restless, 
sleepless,  often  completely  disoriented  and  confused  and  not 
infrequently  dominated  by  hallucinations. 

(b)  In  others,  and  particularly  during  the  night,  delirious 
states  with  sense  deceptions  set  in.  The  patients  are  very  rest- 
less, wander  about,  misconstrue  their  surroundings  in  the  sense 
of  situations  that  have  existed  years  ago,  and  when  confronted 
with  their  errors  show  a  pronounced  tendency  toward  adven- 
turesome confabulations.  When  the  symptom  complex  (am- 
nesia, disorders  of  memory  for  recent  events,  confabulations) 
has  been  fully  developed,  these  cases  are  spoken  of  as  senile 
Korsakoff's  psychosis.  During  the  daytime  such  patients  are 
often  remarkably  collected,  and  amnesia  for  the  delirious  ex- 
periences of  the  night  usually  exists.  This  symptom  complex 
of  senile  Korsakoff's  psychosis  is  preeminently  encountered  in 
senile  dementia  with  focal  lesions. 

(c)  In  still  other  patients  we  find  prolonged  states  of  excite- 
ment accompanied  by  bewilderment  which  are  very  similar  to 
an  acute  hallucinatory  confusion.  The  patients  suffer  from 
motor  agitation,  are  completely  disoriented,  constantly  hallu- 
cinating and  give  expression  to  a  mass  of  paranoiac  and  ex- 
pansive delusions.  These  states  lead,  either  through  exhaus- 
tion or  a  refusal  to  take  food,  directly  to  death,  or  else  they 
disappear  suddenly  and  give  way  to  a  state  of  relative  clearness 
which  afterward  passes  gradually  over  into  a  more  pronounced 
dementia. 

(d)  The  term  "senile  confusion"  is  applied  to  the  most 
marked  senile  mental  disease.  In  this  the  memory  and  the  in- 
telligence as  well  are  so  markedly  reduced  that  the  patients  ap- 
pear to  be  suffering  from  paresis.  They  no  longer  recognize 
their  relatives  and  are  completely  disoriented,  not  knowing 
when  or  where  they  were  born  or  whether  they  are  married, 
have  children,  etc. ;  their  expressional  store  comprises  a  few 
words  which  are  constantly  repeated;  they  are  unable  to  find 


280     THE  UNSOUND  MIND  AND  THE  LAW 

their  own  homes,  rooms  or  beds,  and  lose  themselves  on  the 
street  or  even  in  their  own  houses.  The  most  simple  arith- 
metical calculations  can  no  longer  be  carried  out,  and  the  most 
elementary  geographical  and  historical  facts  have  passed  from 
their  recollection.  Usually  all  kinds  of  vague  delusions,  para- 
noid, expansive,  hypochondriacal  and  depressive  in  nature,  may 
be  demonstrated  to  exist.  These  are  always  nonsensical  and  un- 
critical. Not  infrequent  are  aphasic  disorders,  more  particu- 
larly the  loss  of  nouns.  Often  also  we  observe  in  these  senile 
dements  a  typical  collecting  mania,  in  which  all  imaginable 
kinds  of  valueless  objects,  scraps  of  paper,  pebbles,  etc.,  are 
accumulated.  Their  mood  is  usually  apathetic  or  childishly 
euphoric. 

The  stage  of  paranoid  dementia  is  almost  always  accom- 
panied by  somatic  symptoms  of  senility.  Beside  the  external 
habitus  of  the  aged,  the  arcus  senilis,  the  opacities  of  the  lens, 
general  motor  weakness  and  arteriosclerosis,  we  encounter  senile 
tremor  (shaky  handwriting,  etc.),  hemi-paresis,  attacks  of  diz- 
ziness and  faintness,  pupils  that  are  sluggish  or  reactionless  to 
light,  and  increased  reflexes. 

Attacks  of  dizziness  occur  more  particularly  in  the  morn- 
ing, after  arising.  Patients  who  take  a  rest  during  the  day 
often  experience  brief  states  of  confusion  and  disorientation 
upon  getting  up.  Apoplectic  attacks  leading  to  aphasia  and 
hemiplegia  are  frequent.  Disorders  of  the  functions  of  the 
bladder  and  rectum  are  often  present.  Appetite  and  digestion 
are  extraordinarily  good  in  many  senile  dements. 

(3)  In  the  third  or  terminal  stage,  deep  dementia  is  present 
and,  with  increasing  bodily  decay,  death  supervenes.  The  prog- 
ress of  senile  dementia  usually  covers  a  period  of  from  five 
to  ten  years  but  death  may  occur  in  less  than  three  years  from 
the  time  of  the  onset  of  the  first  symptom.  Under  all  circum- 
stances the  prognosis  is  infaust. 

Differential  Diagnosis 

The  differential  diagnosis  of  senile  dementia  must  be  made 
from  the  following: 

(1)  Paresis.  Pupilary  rigidity,  speech  disorders,  defects  of 
intelligence,  immorality  and  other  symptoms  are  encountered 


THE  PSYCHOSES  OF  INVOLUTION        281 

in  paresis  as  well  as  in  senile  dementia.    Nevertheless  we  must 
note  the  following  distinctions : 

(a)  Senile  dementia  occurs  at  an  advanced  age,  one  at  which 
paresis  is  exceptional. 

(b)  The  course  of  senile  dementia  is  slower  and  more  benign 
than  that  of  paresis. 

(c)  The  disorders  of  memory  in  senile  dementia  are  charac- 
terized by  a  preponderant  weakness  for  recent  events,  while 
the  recollection  for  the  more  distant  past  is  relatively  well 
preserved  and,  during  the  initial  stages,  particularly  so  for 
facts  acquired  in  school.  The  memory  of  paretics  on  the  other 
hand  becomes  affected  fairly  equably  for  occurrences  of  the 
recent  past  and  for  those  more  remote,  and  this  disorder  covers 
particularly  the  elementary  facts  of  school  knowledge. 

(d)  Associated  movements  in  the  distribution  of  the  facial 
nerves  are  infrequent  in  senile  dementia ;  nor  do  the  other  motor* 
disturbances  that  may  be  present  attain  the  same  degree  and  ex- 
tent as  in  paresis. 

(e)  Cataract,  arcus  senilis,  pronounced  arteriosclerosis,  dif- 
ficulty in  hearing  and  the  other  bodily  symptoms  of  senility, 
particularly  when  present  in  combination,  speak  for  senile 
dementia. 

(f)  Senile  tremor  usually  differs  distinctly  from  the  trem- 
orous  ataxia  of  paresis.  Notions  of  grandeur  are  less  frequent 
in  senile  dementia  than  in  paresis. 

(2)  Melancholia.  The  anterograde  disorders  of  memory,  the 
early  onset  of  defective  judgment,  the  more  advanced  age  and 
the  bodily  signs  of  senility  differentiate  senile  dementia  from 
melancholia.  In  this  connection,  of  course,  only  those  forms 
of  senile  dementia  that  have  a  melancholic  initial  stage  can 
cause  any  diagnostic  difficulty. 

(3)  The  Pre-Senile  Paranoid  State.  Details  for  the  estab- 
lishment of  this  diagnosis  will  be  found  in  the  following  chap- 
ter. 

(4)  Manic  Depressive  Insanity.  The  commencement  of  this 
trouble  in  advanced  age  is  very  rare.  When  it  does  occur,  the 
question  will  be  one  of  differentiating  the  manic  phase  from  a 
senile  mania  and  the  melancholic  phase  from  senile  depres- 
sion. In  senile  dementia  the  cardinal  symptoms  of  the  manic 
pr  of  the  depressive  phase  of  circular  insanity  are  but  incom- 


'J82  THE  UNSOUND  MIND  AND  THE  LAW 

pletely  developed;  on  the  other  hand  mental  enfeeblement^ 
which  is  absent  in  manic  depressive  insanity,  is  clearly  demon- 
strated. 

(5)  Hallucinatory  Confusion.  This  state  may  also  occur  in 
old  age  and  result  in  recovery.  It  may  be  confounded  with  the 
delirious  confusional  states  of  senile  dementia.  The  course  of 
the  disease  will  establish  the  diagnosis  with  certainty. 

Forensic  Aspects 

Criminal  offenses  by  senile  dements  are  not  of  frequent  oc- 
currence. Those  that  occur  most  often  are  sexual  delinquen- 
cies, small  thievery,  perjury  and  occasionally  personal  injury 
as  a  result  of  delusions  of  jealousy. 

If  it  be  remembered  that  deviations  of  an  ethical  nature, 
particularly  in  the  sexual  domain,  are  amongst  the  earliest 
signs  of  senile  involution,  such  happenings  will  but  rarely  be 
misinterpreted.  .Not  only  sexual  excesses  and  offenses  against 
decency,  but  also  promises  to  marry  and  even  marriage  itself 
are  not  infrequent  results  of  the  perversions  of  sexual  sense 
that  occur  in  old  age. 

Questions  relating  to  the  establishment  of  guardianship  and 
to  testamentary  capacity  are  very  much  more  complicated  and 
difficult  to  decide.  The  capability  of  making  a  valid  testa- 
ment certainly  cannot  be  denied  to  the  old  person  with  physio- 
logically enfeebled  mentality,  but  in  every  instance  in  which 
such  enfeeblement  is  marked  and  pathological  it  will  be  neces- 
sary to  determine  how  much  mentality  still  exists  and  how 
much  has  been  lost.  Particularly  in  the  case  of  enfeebled  will 
power  must  the  possibility  of  undue  influence  be  considered. 

2.    Pre-Senile  Paranoid  Insanity 

Pre-senile  paranoid  insanity  is  a  rare  form  of  mental  disease. 
It  represents  a  symptom  complex  similar  to  that  of  paranoia, 
develops  during  the  fifth  decade  of  life  and  occurs  chiefly  in 
women.  The  commencement  of  the  psychosis  may  be  entirely 
like  the  initial  stage  of  paranoia.  The  patients  are  depressed 
and  suspicious.  Later  in  the  course  of  the  disease  delusions  set 
in  which  may  be  distinguished  from  those  of  true  paranoia  by 
the  following  characteristics: 


THE  PSYCHOSES  OF  INVOLUTION        283 

(1)  From  their  inception  they  are  absurd  and  fanciful  to 
the  point  of  weakmindedness.  The  patient  believes  a  band  of 
robbers  is  dwelling  in  the  cellar  of  the  institution  and  plying 
their  infamous  trade  therefrom;  that  they  are  slaughtering  the 
patient's  children,  intercepting  her  mail,  attempting  to  put 
poison  in  her  food,  to  let  out  her  brains  or  to  deprive  her  of 
her  sexual  organs. 

(2)  The  persecutory  notions  of  pre-eenile  individuals  are 
constantly  changing  and  do  not  become  combined  into  a  fixed 
delusional  system.  Now  one,  and  now  another  delusion  appears 
upon  the  scene. 

(3)  The  delusional  notions  of  pre-senile  individuals  up  to  a 
certain  degree  are  susceptible  of  correction,  or  at  least,  the  pa- 
tients may  often  be  talked  out  of  their  delusions.  True,  when 
this  is  done,  new  delusions  arise  to  take  their  place. 

(4)  Very  often  the  idea  of  marital  infidelity  on  the  part  of 
husband  or  wife  stands  out  prominently  in  the  variegated 
mass  of  paranoid  delusions. 

(5)  Ideas  of  persecution  of  pre-senile  individuals  have  no 
mandatory  influence  upon  their  conduct.  A  true  paranoic  char- 
acter is  not  developed.  The  pre-senile  paranoiacs  usually  re- 
main harmless  and  often  associate  in  a  most  amicable  manner 
with  their  supposed  enemies  or  with  the  conjugal  partner,  by 
whom  they  believe  themselves  to  be  persecuted  or  deceived. 
Patients  of  this  type  always  remain  passive  toward  their  perse- 
cutors. 

(6)  Sense  deceptions,  more  particularly  hallucinations  of 
hearing,  may  be  present  but  they  play  no  marked  role.  All  in 
all,  the  disease  reminds  one  of  some  cases  of  dementia  preecox 
except  that  older  individuals  are  the  victims. 

The  prognosis  is  unfavorable.  Although  the  process  does 
not  lead  to  actual  dementia,  an  increasing  enfeeblement  of  judg- 
ment and  an  increasing  irritability  develop,  and  the  delusions 
persist  unchanged. 

Differential  Diagnosis 

Pre-senile  paranoid  insanity  must  be  differentiated  from  the 
following : 

(1)    Paranoia.     The  signs  we  have   already  mentioned  as 


284    THE  UNSOUND  MIND  AND  THE  LAW 

characteristic  of  the  delusions  of  the  pre-senile  paranoiac  speak 
against  a  true  paranoia.  The  age  also,  as  well  as  the  early  onset 
of  the  enfeehlement  of  judgment,  speaks  for  a  pre-senile  para- 
noiac state. 

(2)  A  Beginning  Senile  Dementia.  The  diagnosis  in  senile 
dementia  is  based  upon  the  disorders  of  memory  and  intelli- 
gence and  upon  the  pronounced  dimming  of  thought  process  and 
of  orientation,  as  well  as  upon  the  progressive  dementia.  The 
pre-senile  paranoiac  usually  remains  permanently  upon  a  cer- 
tain unvarying  plane  of  outward  collectedness  and  proper  so- 
cial behavior,  while  the  senile  dement  sinks  deeper  and  deeper. 

(3)  Paresis.  Exceptionally  a  late  paresis  may  present  the 
psychic  symptom  complex  of  the  pre-senile  paranoid  state.  In 
such  instances,  however,  the  signs  of  organic  lesion  as  well  as 
the  existing  defects  of  intelligence  will  make  the  diagnosis  of 
paresis  possible. 

3.    Hystero-Hypochondriasis 

Hystero-hypochondriasis  is  not  recognized  by  some  writers  as 
an  independent  psychosis.  Nevertheless  it  must  be  acknowl- 
edged that  this  term  covers  a  well  characterized  picture  of  dis- 
ease that  is  often  observed.  As  a  matter  of  practical  conveni- 
ence, it  will  therefore  be  well  to  devote  a  special  chapter  to  this 
affection. 

Hystero-hypochondriasis  always  develops  at  a  rather  advanced 
period  of  life,  in  women  around  the  climacterium,  and  in  men 
about  the  fiftieth  year  of  life.  It  represents  a  typical  variety  of 
melancholia  and  for  this  reason  has  been  designated  by  French 
writers  as  "melancolie  liypochondrique."  Not  infrequently  it 
arises  upon  the  basis  of  an  hysterical  temperament.  It  is  char- 
acterized by  three  series  of  symptoms,  closely  intertwined,  which 
may  be  classified  as  follows: 

(1)  The  Symptoms  of  Hypochondriasis.  These  usually  mark 
the  beginning  of  the  psychosis.  The  patients  have  all  kinds  of 
neurasthenic  complaints,  headaches,  palpitation  and  sleepless- 
ness; they  occupy  themselves  much  with  their  own  bodies,  ex- 
amine their  abdomens,  carefully  look  at  and  palpate  all  parts 
of  the  body,  test  urine  and  feces,  read  popular  medical  works 
and  consult  one  physician  after  another.     Soon  abnormal  sen- 


THE  PSYCHOSES  OF  INVOLUTION        285 

sations,  fear  and  trembling  set  in;  the  patients  have  all  kinds 
of  apprehension;  they  become  depressed,  unable  to  work  and 
lose  interest  in  life.  More  and  more  the  hypochondriacal  de- 
lusions develop;  the  patients  believe  themselves  afflicted  with  a 
severe  incurable  disease,  such  as  heretofore  has  never  been 
known  to  exist  in  any  human  being  and  for  this  reason  must 
be  an  enigma  to  every  physician.  The  fixation  of  this  idea 
represents  the  full  development  of  the  disease  and  then  we 
find  the  following  symptoms: 

(a)  The  hypochondriacal  delusions  constitute  the  kernel  of 
the  disease.  Thus  a  patient  will  say,  ' '  My  insides  are  being  dis- 
solved, my  body  is  entirely  empty;  all  my  entrails  have  gone 
and  now  the  bones  are  going  the  same  way.  The  worst  of  it  all 
is  that  nothing  of  this  can  be  noticed  from  without,  so  that 
no  human  being,  not  even  the  greatest  physician,  can  tell  how 
sick  I  am. "  It  is  by  their  incorrigibility  that  the  hypochondria- 
cal notions  prove  themselves  to  be  delusions.  They  fixate  them- 
selves more  and  more  during  the  course  of  the  disease  and  ul- 
timately take  on  a  noticeable  monotonous  aspect. 

(b)  The  hypochondriacal  delusions  constantly  receive  fresh 
nourishment  from  the  numerous  abnormal  sensations  in  the  skin 
and  the  internal  organs,  which  the  patients  expand  in  a  delu- 
sional and  hypochondriacal  manner.  Pains,  creeping  and  other 
sensations  are  complained  of  and  are  usually  entirely  unin- 
fluenced by  any  means  of  treatment. 

(c)  The  conceptual  circle  at  the  height  of  the  psychosis  is 
markedly  restricted  and  is  concentrated  entirely  upon  the  pa- 
tient's own  self.  The  patients  develop  an  egotism  that  is  typi- 
cal of  hypochondriasis,  become  indifferent  to  everything  unre- 
lated to  their  disease  and  are  able  to  view  only  with  envy  and 
sorrow  the  contentment  of  others.  The  hypochondriac  occupies 
himself  solely  with  his  disease  and  his  main  desire  is  to  find 
an  auditor  to  whom  he  can  pour  forth  his  complaints.  All  his 
lamentations,  however,  bring  him  no  relief. 

(d)  The  will  power  becomes  increasingly  enfeebled;  the  pa- 
tients become  incapable  of  any  kind  of  work,  sit  immovable  for 
hours  at  a  time,  or  else  wander  restlessly  about,  sighing  and 
complaining. 

(2)  The  Symptoms  of  Melancholia. 

(a)  The  patients  show  a  sorrowful  depression  that  is  en- 


286    THE  UNSOUND  MIND  AND  THE  LAW 

tirely  similar  to  that  of  melancholia  and  may  augment  itself  into 
a  state  of  fear.  They  are  deeply  unhappy,  bewail  the  impotence 
of  medical  science  and  constantly  reiterate  their  tales  of  woe. 
The  facial  expression  may  be  that  of  a  typical  melancholia. 
Not  infrequently  the  hystero-hypochondriac  will  commit  suicide. 

(b)  Notions  of  sinfulness  are  not  uncommon  but  they  are 
always  subordinate  to  the  hypochondriacal  ones.  Sometimes 
they  furnish  the  patients  with  an  explanation  for  their  suf- 
ferings and  distress,  the  assumption  being  that  their  suffering 
represents  just  punishment  for  their  sins. 

(3)  The  Symptoms  Resembling  the  Hysterical  Character. 
These  consist  in  a  marked  proclivity  for  exaggeration  and  wil- 
ful deception  and  in  a  pronounced  need  for  attention  and  sym- 
pathy. When  these  patients  have  slept  well,  they  claim  not  to 
have  closed  an  eye;  after  they  have  eaten  well  (and  most  hypo- 
chondriacs really  enjoy  the  pleasures  of  the  table),  they  stren- 
uously deny  having  done  so.  Some  of  them  take  their  food 
surreptitiously,  when  they  believe  themselves  to  be  unobserved, 
in  order  later  to  complain  of  their  total  loss  of  appetite.  Often 
the  slightest  touch  on  the  body  causes  them  to  complain  of  pain. 
Difficulty  in  swallowing  and  in  breathing,  singultus,  meteorism, 
tachycardia,  gastralgia  and  other  hyperaesthetic  and  hysterical 
symptoms  are  not  infrequent. 

Typical  of  all  hystero-hypochondriacs  is  an  extraordinary 
psychogenetic  augmentation  of  all  symptoms,  setting  in  when- 
ever these  patients  are  being  observed  or  when  they  are  being  ex- 
amined by  a  physician.  Then  all  symptoms  are  manifestly  ex- 
aggerated. Marked  tremor,  rudimentary  hysterical  attacks, 
swaying  of  the  body  with  a  tendency  to  fall,  jerking  movements 
of  the  head,  respiratory  spasms,  sweating,  tonelessness  of  the 
voice  and  other  symptoms  similar  to  those  of  hysteria  set  in, 
but  they  soon  diminish  and  pass  away  once  the  observation  of 
the  patient  has  ceased. 

The  course  of  hystero-hypochondriasis  covers  a  period  of 
years.  The  prognosis  is  not  good.  Mere  remissions  that  inter- 
rupt the  disease  for  hours,  days  or  even  weeks  do  occur;  but 
even  in  such  periods  there  is  no  difficulty  in  establishing  the 
presence  and  incorrigibility  of  the  same  hypochondriacal  de- 
lusions that  had  previously  been  present. 


THE  PSYCHOSES  OF  INVOLUTION        287 

Differential  Diagnosis 

The  differential  diagnosis  of  hystero-hypochondriasis  must 
be  made  from  the  following: 

(1)  Hysteria.  True  hysterics  differ  from  hystero-hypochon- 
driacs  by  their  suggestibility,  by  their  greater  emotional  change- 
ability, and  by  the  presence  of  hysterical  stigmata. 

(2)  Melancholia.  The  fear  of  the  hystero-hypochondriac  is 
less  constant,  the  psycho-motor  inhibition  and  the  retardation 
of  thought  processes  are  wanting,  his  self-accusations  and  his 
notions  of  sinfulness  occupy  a  less  prominent  position  in  the 
picture  of  disease.  Remissions,  during  which  all  the  symptoms 
of  the  disease  disappear,  often  occur  in  hystero-hypochondri- 
asis, but  never  in  melancholia.  Unlike  the  melancholiac,  the 
hystero-hypochondriac  usually  takes  ample  nourishment. 

(3)  Paranoia.  In  some  hystero-hypochondriacs  single  vague, 
paranoiac  ideas  loom  up  from  time  to  time.  These  are  never 
systematized  and  exert  no  influence  upon  the  patient's  conduct. 
Uncomplicated  deceptions  of  skin  and  body  sensations  are  en- 
countered only  in  hystero-hypochondriacs ;  when  present  in 
paranoiacs  they  are  accompanied  at  least  by  hallucinations  of 
hearing. 


IV 
THE  INTOXICATION  PSYCHOSES 

1.    Alcoholism 

Typical  of  alcoholic  stimulation  in  every  instance  is  an  in- 
creased facility  of  flow  of  the  psycho-motor  impulses,  manifest- 
ing itself  in  augmented  physical  activity  and  in  diminished  in- 
tellectual efficiency,  the  latter  being  reflected  in  a  loss  of  the 
finer  inhibitions,  an  increase  of  self-confidence,  a  tendency  to 
farcical  joking  and  a  predominance  of  the  baser  instincts.  In 
so  far  as  the  pathological  action  of  alcohol  (intoxication)  is 
concerned,  we  must  distinguish  pathological  states  of  inebriety, 
delirium  tremens,  acute  hallucinosis  of  drinkers,  Korsakoff's 
psychoses,  chronic  alcoholism  and  alcoholic  paranoia. 

A.     PATHOLOGICAL    STATES    OP   INEBRIETY 

From  a  strictly  scientific  viewpoint,  every  inebriety  is  a  men- 
tal disorder  and  is  therefore  pathological;  consequently  the  ex- 
pression "normal  inebriety"  is  really  a  contradictio  in  adjecto. 
But  for  practical  and  more  especially  for  forensic  reasons,  it 
is  advisable  that  a  differentiation  between  normal  and  patho- 
logical inebriety  should  be  made. 

A  pathological  state  of  inebriety  is  one  that  is  accompanied 
by  pathological  manifestations  which  are  not  typical  of  a  simple 
state  of  intoxication.  It  may  be  produced  by  very  large  quan- 
tities of  alcohol  or,  when  an  intolerance  to  alcohol  exists,  by 
small  or  medium  amounts.  It  occurs  solely  upon  the  basis  of  a 
psychopathic  constitution,  congenital  or  acquired. 

It  is  above  all  the  degenerate,  feeble-minded,  epileptic  hysteric, 
neurasthenic,  paretic  or  senile  patient  who  is  subject  to  such 
pathological  states  of  inebriety.  They  manifest  themselves  in 
sudden  pronounced  affects  with  motor  discharges  of  blind  rage, 
in  deep  depression  accompanied  by  vivid  feelings  of  fear,  in 

288 


THE  INTOXICATION  PSYCHOSES  289 

stormy,  manic-like  excitement,  confusion  with  sense  deceptions, 
delusional  notions  and  false  recognition  of  persons,  as  well  as 
in  other  psychotic  states  usually  of  short  duration.  After  the 
attack  a  deep  sleep  often  supervenes  and  upon  awakening  the 
memory  for  the  events  that  have  been  experienced  is  usually 
defective.    Sometimes  complete  amnesia  exists. 

These  states  of  pathological  inebriety  are  of  great  forensic 
importance  and  for  this  reason  the  physician  must  be  con- 
versant with  them.  Many  of  the  so-called  alcoholic  crimes, 
injury  to  person,  homicides  and  suicides,  take  place  in  the 
affect  of  fear  that  accompanies  a  pathological  state  of  inebriety. 
To  know  this  is  quite  as  important  for  the  jurist  as  it  is  for  the 
physician.  The  diagnosis  of  such  a  state  presupposes  the  exist- 
ence of: 

(1)  Deep  Intoxication.  The  presence  of  pupilary  rigidity  is 
of  decisive  significance  for  the  determination  of  this  condition. 

(2)  Intolerance  to  Alcohol.  This  can  be  proven  experi- 
mentally. 

(3)  Abnormal  Psychotic  Symptoms — attacks  of  fear,  sense 
deceptions,  confusions  and,  after  the  attack,  amnesia. 

B.     DELIRIUM   TREMENS 

Delirium  tremens  is  an  acute  psychosis  in  chronic  alcoholics 
(more  particularly  in  drinkers  of  strong  spirits)  characterized 
by  disorientation  (confusion)  as  to  time  and  place,  by  typical 
sense  deceptions  and  tremor.  Every  delirium  tremens  may  be 
divided  into  three  phases: 

(1)  The  actual  outbreak  of  the  delirium  is  usually  preceded 
by  prodromal  manifestations.  At  night  the  patients  pass  into 
an  excited  state,  become  sleepless,  restless  and  apprehensive; 
occasionally  states  of  fear  accompanied  by  profuse  outbreaks 
of  perspiration  set  in,  during  which  the  patients  are  often  be- 
fuddled and  disoriented.  Then,  though  at  first  only  in  the 
night,  single  sense  deceptions,  the  typical  animal  visions  set  in. 
During  the  daytime  the  patients  are  mostly  clear  but  more 
excitable  than  usual,  ill-tempered  and  bewildered.  In  not  a 
few  cases  the  outbreak  of  the  delirium  tremens  is  preceded  by 
one  or  more  epileptic  attacks.  Where  this  happens  we  are  deal- 
ing either  with  an  epileptic  in  whom  the  alcoholic  delirium  is 


290    THE  UNSOUND  MIND  AND  THE  LAW 

episodic,  or  with  a  chronic  alcoholic  in  whom  the  epilepsy  is 
symptomatic.  In  other  cases  all  prodromal  manifestations  may 
be  wanting;  nor  is  it  essential  that  an  alcoholic  excess  should 
have  directly  preceded  the  outbreak  of  the  delirium. 

(2)  The  height  of  the  attacks  is  represented  by  a  picture  so 
typical  that,  once  seen,  it  will  always  be  recognized.  We  ob- 
serve a  restless  anxiety,  as  well  as  the  lax,  coarse,  bloated  traits 
so  characteristic  of  chronic  alcoholism,  markedly  injected  con- 
junctiva?, flattened  naso-labial  folds,  and  not  infrequently  weak- 
ness of  the  facial  musculature.  First  in  evidence  is  the  pro- 
nounced tremor,  which  more  or  less  affects  the  entire  body,  so 
the  patient  can  hardly  retain  his  equilibrium.  The  tremor  is  a 
rapid  one  (eight  to  ten  oscillations  per  second)  and  is  strongest 
in  the  lips,  tongue  and  hands.  It  persists  during  rest  and  in- 
creases upon  voluntary  movement.  The  patient  pays  no  at- 
tention to  his  surroundings,  bundles  up  his  bed  coverings  and 
fumbles  them  about.  He  passes  his  hands  restlessly  over  them 
as  though  he  were  trying  to  brush  something  away,  rivets  his 
attention  upon  the  walls,  looks  under  the  bed  and  clearly  shows 
he  is  occupied  with  visionary  objects.  Now  and  then  an  ap- 
prehensive excitement  sets  in,  the  patient  throws  himself  against 
the  wall  and  with  the  force  of  despair  tries  to  keep  it  from  fall- 
ing upon  him,  even  shouting  for  help.  From  his  talk  we  can 
readily  see  he  believes  himself  to  be  in  his  accustomed  sur- 
roundings and  from  the  manner  in  which  this  mistaken  recogni- 
tion manifests  itself,  we  are  not  infrequently  able  to  deduce 
the  nature  of  the  patient's  every-day  occupation. 

From  objective  signs,  such  as  sitting  up  and  listening,  threat- 
ening, scolding,  and  sudden  outbreaks  of  excitement,  it  is  not 
difficult  to  recognize  the  patient  has  sense  deceptions.  These  are 
predominantly  visual  ones,  but  auditory  and  tactile  hallucina- 
tions are  not  infrequent.  Typical  features  of  alcoholic  delirium 
are  the  following: 

(a)  A  mistaken  recognition  of  the  actual  situation,  arising 
from  the  associative  intertwining  of  the  auditory  and  visual 
hallucinations.  The  patients  fail  to  recognize  they  are  in  a 
hospital  but  believe  themselves  to  be  in  their  usual  surroundings, 
among  their  relatives  and  friends,  whose  voices  they  hear.  The 
physicians  and  nurses,  strangers  to  them,  are  saluted  as  old 
acquaintances.     The  hallucinated  situation  usually  corresponds 


THE  INTOXICATION  PSYCHOSES         291 

to  the  daily  occupation  of  the  hallucinant;  the  waiter  in  his 
delirium  believes  himself  to  be  in  his  restaurant,  the  fisherman 
sees  water  with  fishes,  etc. 

(b)  The  animal  visions.  The  visionary  animals  are  never  at 
rest.  The  patient  sees  and  busies  himself  with  mice,  rats,  and 
larger  animals.  These  visions  may  easily  be  aroused  by  sug- 
gestive means.  For  instance,  when  the  sufferer  from  alcoholic 
delirium  is  shown  certain  spots  upon  the  wall  and  is  asked  to 
watch  them  closely,  he  will  soon  take  them  to  be  spiders,  bugs  or 
similar  creatures. 

(c)  The  tactile  sense  deceptions.  These  are  frequent  and 
for  the  most  part  consist  in  the  feeling  that  small  animals  are 
crawling  under  the  skin.  Actual  pains,  probably  of  a  neuritic 
origin,  are  also  present  and  give  rise  to  the  sensation  of  being 
bitten  or  stung. 

Hallucinations  of  hearing  play  but  a  subordinate  role.  They 
almost  always  constitute  merely  a  supplement  to  the  hallu- 
cinated situation.  The  delirious  patient,  believing  himself  to 
be  employed  at  his  usual  occupation,  hears  voices  of  relatives 
and  acquaintances  and  converses  with  them  regarding  the  hap- 
penings of  the  day.  He  is  fully  orient^  nn  tp  the  beginning 
of  the  delusions  and  gives  accurate  in  7  ucin]1  regarding  him- 
self and  his  entire  past  up  to  that  *s  W1  trograde  mem- 
ory therefore  is  entirely  intact,  ce  Profuse  ^4  °Me  memory 
shows  manifest  incisive  disturban  reflectm^.  ^b^  f  p  matter 
how  often  he  may  be  enlightened. ey  ar^'%5§  ^0;'oT;ia"iented 
as  to  time  and  place  from  the  tin  .  ■  he  .  ^0  ,7  ero&rat  may 
easily  be  demonstrated  experiratanei?e  off  P(^*atance>  nCng 
that  occurs  during  this  time.  >  6il^ffv  ,  rJj:0^-iurnX'^  ^*soi:;- 
acteristic  confabulations.  The  *a}A ,.  *  tes'm  #%efc  ^  *»'" 
imum  intensity  upon  the  thh  %  *%&*,  **e  e  *  e^^ 
are  in  a  state  of  constant  mot-  0t.  *  The  al?  atta;  the  e^ 
symptoms  are  frequent  statos  of  J  SsXeSs  le*ts  D  ^  *k  nja  ' 
constant  profuse  sweating,  genem  *a*±  su^d  #e  ^  that  tjme 
ities,  unsteadiness  of  speech  a^  se^nse^distSbance's  ^2*& 

In  many  instances  toward  the  bid  of  th    a  t  • 
euphoric  state  sets  in.     The  dura^n  of  6,  del™m  a  peculiar 
averages  four  days,  during  which  time  ^      ,      6  lrium  tremens 
the  rule.    Upon  the  last  day  the  hallucinations  Sleeplessness  iie 
patient  is  manifestly  exhausted  and  sinks  into  a  deep^fc^  f 


292    THE  UNSOUND  MIND  AND  THE  LAW 

(3)  This  sleep  represents  the  crisis  of  the  affection  and  lasts 
from  ten  to  twelve  hours  or  longer.  "When  the  patient  awakens 
his  collectedness  has  returned  and  his  orientation  is  reestab- 
lished. Then  the  recollection  for  individual  things  that  have 
taken  place  during  the  delirium  is  often  well  denned  hut,  all 
in  all,  is  rather  vague.  Complete  amnesia  is  rare.  It  occurs 
usually  only  in  the  delirium  that  accompanies  or  follows  epi- 
leptic attacks.  After  the  passing  of  the  delirium,  single  deliri- 
ous experiences  are  still  believed  to  be  actual  occurrences.  The 
tremor  does  not  disappear  until  four  to  six  days  after  the  critical 
sleep. 

It  remains  to  be  noted  that  in  at  least  one-half  of  all  pa- 
tients suffering  from  delirium  tremens,  transitory  albumin- 
uria, usually  of  slight  degree  and  ending  with  the  passing  of  the 
delirium,  is  found  to  exist.  A  large  number  of  sufferers  from 
delirium  tremens  also  have  some  febrile  affection  of  the  respira- 
tory tract.  The  usual  complication  is  pneumonia.  In  such  in- 
stances the  delirium  generally  makes  its  first  appearance  upon 
the  third  or  fourth  day  of  the  pneumonia.  The  prognosis  of 
alcoholic  delirium  complicated  by  pneumonia  is  unfavorable. 

Ten  to  fifteen  py  \    l   -f  patients  thus  affected  die. 
a  the  for 

,  « Yenx  ooutl1 
up li  hims'i^  Diagnosis 

A  ty    ^  J-'i'D-vrenv-    cannot  be  confounded  with  any 

other  Pical  rleliriur*  t*       "\„iowever,  a  number  of  cases  that 
devf    psychosis.    Ther^  aTe,     *t  from  the  pure  alcoholic  de_ 

liriate  to  a  greater  o*  ^s  designated  ^  at     ical  deliriums. 
T  ium  and  therefore  must  be  a 

hese  are:  „„,™™ed  or  Preceded  by  Epileptic 

(1)  The  Deliriums  Accompam  *      *     * 

\x;   *u.^  **  )y-  deep  cloudedness  of  con- 

Spells.     They  are  d""*""*    olated  delusionS)  and  by  the 

piousness,  by  *°  ^^.fjlght  processes,  which  in  the 
monotony  and  inhibition  of  the  trv  .  *  a-    '  .        ., 

patienHuffering  from  a  typical  de  mum  are  flighty  and  easily 
deflected      Other   characterises   are   single   hallucinations  of 
d  smell    the  frequ^b'  occurring  mimical  misinterpre- 

■faste  an        ,      '  ,1T~ri^s  and  the  occasional  impulsive  re- 

itions  of  the  surrour1.   to  .      .  * 

ac"  ..,L-&clinous   amnesia  is  usually  more   intense 

tha10ns'      -  cypiccl  alcoholic  delirium, 
n.  > 


THE  INTOXICATION  PSYCHOSES  293 

(2)  The  Severe  Deliriums  with  Meningitic  Manifestations. 
These  are  accompanied  by  high  fever.  In  this  delirium  tremens 
febrile,  the  knee  jerks  may  he  absent  and  palsies  of  ocular  mus- 
cles and  other  cerebral  symptoms  may  be  present.  In  very 
doubtful  cases  the  anamnesis  should  serve  to  establish  the 
correct,  though  difficult,  diagnosis. 

C.     ACUTE   HALLUCINOSIS    OF   DRINKERS 

Acute  alcoholic  hallucinosis  is  a  psychosis  characterized  by 
numerous  hallucinations  of  hearing  and  by  the  rapid  develop- 
ment of  connected  paranoiac  delusions  with  complete  preserva- 
tion of  orientation.  It  has  various  symptoms  in  common  with 
delirium  tremens.  Like  the  latter  it  develops  upon  a  basis  of 
chronic  alcoholism,  usually  begins  acutely,  runs  a  rapid  course 
of  a  few  days  or  weeks,  and  ends,  at  any  rate  when  we  are 
dealing  with  a  first  attack,  in  complete  recovery.  Weakened 
facial  innervation,  light  palsies,  tremor  and  neuritic  symptoms 
are  present  as  in  alcoholic  delirium,  but  acute  hallucinosis  dif- 
fers from  the  latter  essentially  by  the  following  symptoms. 

(1)  While  in  delirium  tremens  it  is  the  visual  hallucinations 
that  occupy  the  foreground,  in  acute  hallucinosis  the  auditory 
hallucinations  are  most  frequent.  It  is  with  these  that  the 
psychosis  usually  begins.  They  are  profuse  and  of  a  threaten- 
ing, vituperative  nature,  usually  reflecting  upon  the  patient's 
dissolute  mode  of  life.  Often  they  are  particularly  character- 
ized as  follows: 

(a)  By  the  number  and  simultaneity  of  the  voices  (beggar, 
drunk,  gutter-snipe,  etc.). 

(b)  By  the  marked  rhythmical  monotony  of  what  the  voices 
say,  like,  "You  are  a  beast,  you  are  a  beast,"  repeated  and  re- 
peated in  an  unvarying  tone  of  voice  and  with  unchangeable 
emphasis. 

(c)  Not  infrequently  the  hallucinations  form  connected  con- 
versations of  several  voices  that  talk  about  the  patient  in  a  de- 
risive manner  and  to  which  the  patient  himself  is  merely  an 
inactive  listener. 

(d)  Less  frequent  is  thought  audition. 

(2)  The  second  fundamental  symptom  of  acute  hallucinosis 
is  represented  by  the  paranoiac  delusions  that  occur  in  a  more  or 


294    THE  UNSOUND  MIND  AND  THE  LAW 

less  systematized  manner,  are  initiated  by  superficial  reasons 
and  are  often  subject  to  rapid  changes.    Here  we  find: 

(a)  Aspersive  delusions  very  frequently  present,  especially 
in  the  beginning  of  the  psychosis. 

(b)  A  more  or  less  logically  connected  chain  of  persecutory 
ideas — for  instance,  the  patient  will  say,  "The  voices  are  those 
of  wicked  enemies.  It  is  a  band  of  villains,  a  secret  society. 
They  can  fly  through  the  air  without  being  seen.  It  is  an  as- 
sociation of  invisible  persons,  I  am  to  be  killed  because  I  am 
said  to  have  revealed  their  secrets." 

(c)  Occasionally  also  delusions  of  jealousy  manifest  them- 
selves. 

The  psychosis  begins  and  is  accompanied  by  pronounced 
affects  of  fear,  during  which  the  patients,  tormented  by  voices, 
not  infrequently  appeal  to  the  police  for  protection,  or  even 
commit  suicide.  Very  often  the  apprehension  is  particularly 
pronounced  in  certain  hallucinations,  the  patients  for  instance 
hearing  a  constant  firing  of  guns  and  seeing  their  enemies  aim- 
ing at  them.  Besides  the  auditory  hallucinations,  visions  of 
animals,  as  of  scorpions,  weasels,  small  bears,  etc.,  are  excep- 
tionally present.    Tactile  hallucinations  are  not  uncommon. 

Actual  delusions  of  grandeur  are  unusual  and  when  they 
do  occur  are  of  no  diagnostic  significance.  Often  we  meet  with 
a  transitory  exalted  self-appreciation  that  receives  its  special 
alcoholic  impress  from  a  humoristieally  tinged  euphoria. 

The  differential  diagnosis  of  this  acute  hallucinosis  from  de- 
lirium tremens  and  paranoia  becomes  clear  from  what  we  have 
already  said.  It  should  be  particularly  noted  that  paranoiac 
delusions  occur  in  acute  alcoholic  hallucinosis  but  not  in  de- 
lirium tremens,  while  disorientation,  disorders  of  attentiveness, 
disorders  of  memory  for  recent  events,  confabulations  and  the 
erroneous  recognition  of  conditions  are  met  with  in  delirium 
tremens  and  not  in  acute  alcoholic  hallucinosis. 

d.    Korsakoff's  psychosis 

The  chronic  alcoholic  delirium  first  described  by  Korsakoff 
is  known  also  as  polyneuritic  psychosis.  Tt  develops  most  fre- 
quently in  chronic  alcoholics  after  severe  excesses  in  drinking. 
In  the  commencement  there  is  present  either  a  multiple  neuritis 


THE  INTOXICATION  PSYCHOSES         295 

that  is  followed  by  a  phase  of  acute  delirium,  or  a  more  or  less 
atypical  delirium  in  the  course  of  which  symptoms  of  poly- 
neuritis set  in.  The  initial  delirious  phase,  however,  does  not 
pass  directly  from  the  typical  sleep  into  recovery  as  in  ordinary 
alcoholic  delirium,  but  goes  over  into  a  chronic  state,  so  that 
in  the  course  of  several  weeks  the  pronounced  symptom  complex 
of  Korsakoff's  psychosis  is  developed. 

The  patient  who  in  the  beginning,  especially  at  night,  still 
manifested  symptoms  of  delirium,  becomes  quiet  and  outwardly 
composed,  but  the  emotional  state  is  a  peculiar  one.  Ordinarily 
there  exists  a  marked  apathy,  interrupted  only  at  times  by  a 
plaintive  lachrymose  behavior  or  by  causeless  euphoria.  The 
outward  comportment  of  the  patient  is  perfectly  correct  and 
would  not  lead  one  to  assume  the  existence  of  any  more  deeply 
lying  disorder.  The  cardinal  symptoms  of  Korsakoff's  psy- 
chosis at  its  height  are  the  following : 

(1)  The  most  noticeable  is  the  pronounced  disorder  of  the 
capacity  for  acquiring  new  knowledge,  as  shown  by  the  defects 
of  memory  for  recent  events.  The  patients  do  not  know  where 
they  are,  do  not  recognize  their  surroundings  and  therefore 
constantly  make  erroneous  statements  in  regard  to  time,  place 
and  recent  happenings.  After  they  have  been  accurately  in- 
structed and  completely  oriented,  they  will  within  a  few  min- 
utes have  forgotten  all  that  has  been  told  them  and  repeat  the 
previous  erroneous  statements.  Similarly  everything  that  takes 
place  in  their  presence  passes  by  them  without  effect.  Hence 
these  patients  also  lose  all  conception  of  the  sequence  of  events ; 
they  have  no  idea  how  long  they  have  been  where  they  are, 
they  lose  every  consideration  of  the  flight  of  time  and  often  do 
not  know  whether  it  is  day  or  night. 

(2)  In  addition  to  the  pronounced  disorder  of  recollection 
for  recent  events,  there  exists  usually  a  more  or  less  far-reach- 
ing retrograde  amnesia  which  may  cover  a  period  antedating 
the  delusions  by  months  and  even  years.  The  entire  affected  pe- 
riod then  is  virtually  wiped  from  the  memory ;  the  patients  have 
forgotten  even  the  most  important  personal  experiences,  the 
most  noteworthy  political  happenings  of  the  age,  and  know 
nothing  of  their  marriage,  of  the  death  of  their  relatives  and 
other  incidents  of  their  lives,  provided  these  occurrences  have 
fallen  within  the  scope  of  the  period  covered  by  the  amnesia. 


296    THE  UNSOUND  MIND  AND  THE  LAW 

Sometimes  they  believe  themselves  to  be  in  some  other  period 
of  their  lives,  the  confines  of  which  are  not  reached  by  the  ante- 
rograde amnesia.  Thus  one  of  my  patients,  a  professor  at  a 
university,  believed  himself  still  to  be  a  student  at  the  college 
from  which  he  was  graduated. 

(3)  The  patients  endeavor  to  conceal  these  marked  defects 
of  memory  by  persistent,  but  always  different  confabulations. 
When  asked  a  question  they  are  never  embarrassed  for  an 
answer,  but  the  reply  they  give  clearly  bears  the  impress  of 
confabulation.  The  next  moment,  however,  this  confabulation 
has  been  forgotten  and  a  repetition  of  the  same  question  will 
elicit  another  and  equally  novel  canard.  In  many  instances 
this  characteristic  of  confabulation  is  so  pronounced  that  it 
occupies  the  foreground  of  the  entire  picture.  The  patients 
recount  the  most  adventurous  experiences,  most  fantastically 
adorned  and  not  infrequently  bearing  so  grandiose  an  impress 
that  they  resemble  the  notions  of  the  paretic.  But  the  experi- 
ences of  the  distant  past  that  have  not  been  affected  by  the 
amnesia  are  reported  correctly  and  concisely.  In  other  ways, 
also,  the  power  of  thought  is  generally  unaffected. 

The  outcome  of  the  psychosis  of  Korsakoff  is  a  varying  one. 
Complete  recovery  is  infrequent.  Usually  after  a  duration  of 
months  or  years  the  chief  symptoms  fade  away  while  a  state  of 
mental  enfeeblement  persists. 

Differential  Diagnosis 

"Where  the  symptom  complex  of  this  psychosis  is  fully  de- 
veloped a  differentiation  may  have  to  be  made  from  the  fol- 
lowing : 

(1)  Dementia  Paralytica.  The  neuritic  symptoms,  the  palsies 
and  paralyses  of  peripheral  and  cranial  nerves,  the  muscular 
atrophies  with  reaction  of  degeneration,  the  weakness  or  ab- 
sence of  the  knee  jerks,  and  the  disorders  of  speech  and  sensa- 
tion, all  of  which  are  present  in  the  beginning  and  in  the  early 
stages  of  Korsakoff's  psychosis,  may  in  conjunction  with  the 
psychic  symptoms,  anterograde  and  retrograde  affection  of  the 
memory,  resemble  the  picture  of  dementia  paralytica.  Even 
pupilary  rigidity  is  encountered  in  pronounced  alcoholic  in- 
toxication.    An   anamnesis  showing  the   existence   of  marked 


THE  INTOXICATION  PSYCHOSES         297 

alcoholic  excesses,  an  onset  with  a  delusional  phase,  the  peculiar 
disorder  of  memory,  and  the  course  and  outcome  will  determine 
the  diagnosis.  In  the  majority  of  instances  a  certain  ameliora- 
tion will  set  in  and  the  condition  then  remains  at  least  station- 
ary. In  dementia  paralytica  on  the  other  hand,  constant  de- 
terioration takes  place. 

(2)  Dementia  Senilis.  In  senility,  too,  disorders  of  memory 
for  recent  events,  a  tendency  to  confabulations  and  amnesia 
are  encountered.  This  symptom  complex,  however,  is  generally 
the  result  of  an  existing  senile  dementia  and  differs  from 
chronic  alcoholic  delirium  by  the  absence  of  neuritic  symptoms, 
by  the  signs  of  senility  and  by  its  occurrence  in  spells,  which 
usually  supervene  at  night. 

E.      CHRONIC  ALCOHOLISM 

Chronic  alcoholics  or  habitual  drinkers  usually  have  a  facial 
expression  so  characteristic  that  the  diagnosis  can  present  no 
difficulty  even  to  the  non-alienist.  The  relaxed  bloated  traits 
and  the  sodden  face,  with  superficial  or  obliterated  furrows, 
the  injected  conjunctivas,  the  more  or  less  prominent,  dull, 
suffused  eyes  and  the  marks  of  premature  old  age  are  most 
always  pronounced  and  unmistakable.  Psychotically,  chronic 
alcoholism  is  characterized  in  the  following  manner: 

(1)  Above  all,  it  is  the  intellect  that  suffers  from  the  per- 
sistent alcoholic  poisoning.  The  patients  become  more  and 
more  incapable  of  regular,  persistent  work  and  they  tire  easily. 
At  the  same  time  their  will  power  becomes  more  and  more 
enfeebled  until  finally  their  energy  wanes  to  such  an  extent 
that  even  when  their  intelligence  still  permits,  they  are  unable 
to  arouse  themselves  to  any  positive  action.  It  is  precisely  in 
this  early  and  persistent  palsy  of  the  will  that  the  danger  of 
chronic  alcoholism  lies.  The  habitual  drinkers  sink  lower  and 
lower  in  the  social  scale  and  while  in  the  beginning  there  is 
present  a  certain  humorous  and  satirical  appreciation  of  the 
situation,  there  develops  later  that  complete  lack  of  insight  and 
appreciation  for  the  weakened  condition  that  is  so  thoroughly 
characteristic  of  the  deteriorated  alcoholic. 

(2)  The  memory  suffers  in  an  augmenting  degree.    It  is  not 


298    THE  UNSOUND  MIND  AND  THE  LAW 

only  the  faculty  to  gather  and  retain  new  impressions,  but  also 
the  recollection  for  the  far  distant  past  that  is  impaired. 

(3)  The  decline  in  intellectual  power  is  associated  with  a  moral 
degeneration  of  greater  or  lesser  degree.  The  chronic  alco- 
holics neglect  their  duties  and  their  families  without  fear  or 
shame,  disregard  the  requirements  of  custom  and  breeding  and 
become  indifferent  to  the  censure  and  disdain  with  which  they 
are  treated.  The  alcohol  obliterates  all  the  better  instincts  they 
may  have,  until  finally,  all  sense  of  propriety  being  lost,  the 
victims  are  governed  solely  by  their  desire  for  drink,  notwith- 
standing the  fact  that  a  steady  decrease  in  their  tolerance  of  the 
poison  has  set  in.  In  nearly  all  chronic  alcoholics  there  are 
developed  certain  peculiarities  of  temperament  that  may  fit- 
tingly be  designated  as  constituting  the  character  of  the 
habitual  drinker.  These  alcoholics  always  show  two  sides,  the 
one  representing  their  conduct  in  their  own  homes  and  the 
other  their  behavior  in  the  club  or  saloon.  At  home  they  are 
tyrants  who  by  threats  and  brutality  seek  to  regain  the  respect 
they  have  forfeited;  or  else  they  are  entirely  irresolute,  and, 
whiningly  and  whimperingly,  they  endeavor  by  means  of  hypo- 
critical promises  and  flagrant  lies  to  obtain  more  money  with 
which  to  purchase  drink.  In  the  drinking  place,  on  the  con- 
trary, they  show  their  most  amiable  side;  their  mood  is  elated, 
manifesting  itself  in  cynical  inane  jokes,  vapid  boastfulness 
and  imbecile  confabulations.  Those  two  kinds  of  behavior, 
totally  different  as  they  are,  represent  the  effect  of  alcoholic 
abstinence  upon  the  one  hand  and  renewed  intoxication  upon 
the  other. 

(4)  Characteristic  of  all  chronic  alcoholics  is  the  complete 
lack  of  appreciation  of  their  own  deplorable  state.  These  pa- 
tients are  convinced  of  their  own  importance,  are  exaggeratedly 
self-satisfied  and  for  this  reason  cannot  comprehend  why  their 
relatives  should  condemn  them.  They  see  everything  in  a  dif- 
ferent light,  distort  everything  to  make  it  appear  to  their  own 
advantage  and  in  so  doing  not  infrequently  manifest  consid- 
erable readiness  and  skill. 

In  many  chronic  alcoholics  epileptic  attacks  set  in,  but  these 
may  disappear  after  a  long  period  of  abstinence.  Where  the 
attacks  persist  we  are  dealing  with  epileptic  individuals  or  with 


THE  INTOXICATION  PSYCHOSES         299 

such  as  are  epileptically  predisposed  and  in  whom  the  alcohol 
acts  as  the  exciting  cause. 

In  general  the  diagnosis  of  chronic  alcoholism  is  easy.  The 
anamnesis  in  itself  will  easily  enable  us  to  arrive  at  a  decision. 
In  addition  to  the  psychotic  symptoms  of  deterioration  the  phys- 
ical symptoms  will  aid  us.  These  are  tremor,  gastric  disturb- 
ances, disorders  of  the  heart,  liver  and  nervous  system,  arterio- 
sclerosis, neuritic  symptoms,  sluggishly  reacting  pupils,  etc. 

All  in  all  the  prognosis  of  chronic  alcoholism  is  bad.  Where- 
soever an  incorrigible  misjudgment  of  the  existing  situation  has 
set  in,  with  failure  by  the  patients  to  recognize  their  own  condi- 
tion, improvement  or  recovery  can  no  longer  be  expected.  In 
such  cases  we  are  dealing  with  a  dementia,  the  sufferers  from 
which  are  no  longer  to  be  looked  upon  and  treated  as  "simple 
deteriorates,"  but  as  insane  individuals. 

Differential  Diagnosis 

In  some  instances  the  differential  diagnosis  between  chronic 
alcoholism  and  dementia  paralytica  may  present  difficulties. 
Marked  dementia,  absent  knee  jerks,  pupilary  rigidity,  con- 
vulsive attacks  and  other  symptoms  of  paresis  may  create  a 
suspicion  of  the  existence  of  this  disease.  But  the  anamnesis 
with  the  absence  of  any  indication  of  a  luetic  infection,  as  well 
as  the  slight  progression  and  the  more  or  less  far-reaching  re- 
missions during  the  periods  when  no  alcohol  is  taken,  will,  after 
prolonged  observation,  enable  a  correct  diagnosis  to  be  made. 

Not  infrequently  paretics  give  themselves  up  to  alcoholic 
debauches.  Then  the  alcoholism  is  merely  a  symptom  of  paresis 
and  even  prolonged  total  abstinence  will  be  unaccompanied  by 
an  improvement  in  the  patient's  condition.  The  disease  takes 
its  inevitable  course. 

F.      ALCOHOLIC  PARANOIA 

In  not  a  few  chronic  alcoholics,  paranoiac  delusions  of  a 
more  or  less  systematized  nature  develop.  Most  frequent  is  the 
delusion  of  jealousy.  The  aversion  which  the  marital  consort 
so  often  experiences  toward  the  more  and  more  deteriorating 
alcoholic,  the  sexual  impotence  that  follows  the  long  use  of 


300    THE  UNSOUND  MIND  AND  THE  LAW 

alcohol  and  the  marked  enfeeblement  of  judgment  constitute 
the  basis  upon  which  these  delusions  develop.  All  kinds  of 
insignificant  occurrences  furnish  the  nutriment  for  the  notion 
of  jealousy  until  finally  the  patients  are  convinced  of  the  in- 
fidelity of  their  conjugal  partners.  Gross  maltreatment,  dan- 
gerous physical  injury  or  murder  are  the  resulting  offenses. 
This  delusion  of  jealousy  in  chronic  alcoholics  presents  a  bad 
prognosis.  Prolonged  abstinence  may  produce  remissions,  but 
recovery  is  exceptional.  Besides  the  notion  of  jealousy,  other 
paranoid  semblances  may  be  present  in  chronic  alcoholics.  Thus 
not  infrequently  delusions  of  being  poisoned  combined  with 
hypochondriacal  notions  are  encountered. 

We  occasionally  meet  with  pure  delusions  of  jealousy  which 
are  not  part  of  a  paranoia  and  for  which  an  alcoholic  genesis 
can  with  certainty  be  excluded.  The  hallucinations  that  as  a 
rule  accompany  the  delusions  of  jealousy  of  the  alcoholic  are 
not  present  in  such  cases. 

Forensic  Aspects 

The  forensic  significance  of  Korsakoff's  psychosis  is  to  be 
sought  mainly  in  the  patient's  enfeeblement  of  memory.  In 
consequence  of  their  pronounced  memory  defects  they  are  easily 
victimized  and  also  forget  the  obligations  they  have  incurred. 
Their  irritability  leads  to  attacks  upon  others.  That  such  pa- 
tients can  have  no  valid  testamentary  capacity  must  be  self- 
evident. 

The  apprehensive  excitement  that  accompanies  the  alcoholic 
delirium  gives  the  impress  to  the  forensic  relations  established 
by  this  state.  The  patients  endeavor  to  protect  themselves 
against  their  supposed  persecutors,  attack  people  about  them 
and  create  public  disturbance. 

The  practical  forensic  relations  of  the  chronic  alcoholic  psy- 
choses are  similar  to  those  of  paranoia. 

Nothing  need  be  said  regarding  these  same  relations  of  the 
actual  alcoholic  psychoses,  for  once  their  existence  at  the  time 
of  the  commission  of  an  offense  is  established  the  irresponsibility 
of  the  offender  is  also  proved.  This  from  a  medical  point  of 
view  should  also  apply  to  those  transitory  psychic  disorders 
dependent  upon  acute  alcoholic  intoxication,  for  there  can  be 


THE  INTOXICATION  PSYCHOSES         301 

no  actual  difference  between  the  states  of  disordered  conscious- 
ness due  to  alcohol  and  those  due  to  other  causes.  But  because 
the  intoxicated  person  is  responsible  for  having  brought  about 
his  condition  and  the  resultant  consequences,  the  law  does  not 
look  upon  them  as  states  of  pathologically  disordered  conscious- 
ness. This  is  an  anomalous  situation  which  should  be  remedied, 
perhaps,  as  Ziehen  has  suggested,  by  punishing  the  negligence, 
which  under  certain  circumstances  may  be  criminal,  that  has 
led  up  to  the  production  of  the  temporary  state  of  mental 
disorder. 

The  expert  estimation  of  the  chronic  alcoholic  states  will 
have  to  be  effected  in  accordance  with  the  degree  of  disorder 
that  exists  in  each  individual  case. 

2.    Morphinism 

Chronic  misuse  of  morphine,  like  chronic  misuse  of  alcohol, 
leads  to  mental  and  physical  derangement.  Just  as  certain 
symptoms  are  characteristic  in  the  habitual  drinker,  so  in  the 
habitual  morphinist  certain  symptoms  are  typical.  These  are 
as  follows: 

(1)  A  more  or  less  deep  intellectual  decay.  The  will  power 
becomes  markedly  affected  from  the  very  beginning,  so  that 
all  initiative  is  lost.  The  memory  also  becomes  weakened,  the 
recollection  of  occurrences  for  recent  events  suffers,  and  associ- 
ative thought  becomes  hampered  and  retarded  until  finally  any 
mental  occupation  becomes  impossible. 

(2)  "With  the  intellectual  decline  there  develops  an  increas- 
ing moral  deterioration.  This  not  infrequently  develops,  as 
does  the  morphinism,  itself,  upon  the  basis  of  an  hysteria  or 
upon  that  of  an  existing  abnormal  disposition  of  character. 
Nearly  all  morphinists  become  pronounced  egotists  so  that  they 
lose  interest  in  practically  everything,  even  what  has  been  most 
dear  to  them,  and  their  entire  thoughts  center  upon  the  manner 
in  which  they  may  obtain  the  drug  they  crave.  They  become 
abject  slaves  and  shrink  from  nothing  in  order  to  satisfy  their 
need.  Deception,  lies,  theft,  embezzlement  and  forgery  are  the 
offenses  to  which  this  slavery  leads.  Among  female  drug  ad- 
dicts, prostitution  in  order  to  obtain  money  to  purchase  mor- 
phine is  of  frequent  occurrence. 


302    THE  UNSOUND  MIND  AND  THE  LAW 

(3)  Morphinists  often  develop  traits  that  are  manifestly 
hysterical  notwithstanding  that  these  patients  can  in  no  sense 
be  elassed  as  hysterics.  More  particular  mention  should  be 
made  of  a  strong  tendency  to  exaggeration  and  of  the  psycho- 
genic increase  of  many  symptoms  whenever  the  patients  are 
being  observed. 

Accompanying  the  marks  of  psychic  failure  we  find  those  of 
physical  decline — emaciation  of  high  degree,  gastrointestinal 
disturbances,  ataxia,  sexual  impotence  and  amenorrhea.  Often 
we  find  present  a  miosis,  which  occasionally  is  associated  with 
pupilary  rigidity.  The  teeth  usually  become  loose  and  must 
be  extracted.  Tremor  is  often  present,  but  is  not  so  marked 
as  in  alcoholism.  Special  manifestations  are  produced  by  with- 
drawal of  the  drug.  Then,  as  in  the  sudden  withdrawal  of 
alcohol,  certain  so-called  abstinence  manifestations  set  in.  Rest- 
lessness, with  the  sensation  of  impending  collapse,  states  of  fear 
that  lead  to  suicide,  loss  of  appetite,  constant  sneezing  and 
yawning,  eructations  and  vomiting,  diarrhoea,  augmenting 
tremor,  cramps  in  the  calves,  pains  in  various  muscular  terri- 
tories, neuralgia  and  paresthesias,  sleeplessness,  general  pros- 
tration, and,  when  the  withdrawal  is  a  sudden  one,  delusional 
states  similar  to  those  due  to  alcohol,  accompanied  by  visions 
of  animals  and  disorientation,  all  of  which  may  be  dispelled  by 
ample  injections  of  morphine,  have  been  observed.  Occasionally 
the  sudden  complete  withdrawal  has  been  followed  by  collapse 
and  coma.  Hysterical  attacks  occurring  in  morphinists  during 
the  abstinence  period  are  very  frequent.  In  such  instances  it  is 
probable  that  the  morphinism  has  developed  upon  an  hysterical 
basis. 

The  diagnosis  of  morphinism  should  hardly  present  any  dif- 
ficulties. From  chronic  alcoholism  it  may  be  differentiated  by 
an  absence  of  irritability  and  by  an  enfeeblement  and  a  re- 
tardation of  the  psycho-motor  impulses.  The  deteriorated  alco- 
holic is  usually  given  to  explosions  and  is  ready  for  active  ex- 
cesses while  the  deteriorated  morphinist  is  sluggish,  apathetic 
and  generally  in  a  marked  state  of  dreamy  cloudedness.  In 
cases  in  which  the  anamnesis  is  wanting  the  diagnosis  may  be 
aided  by  miosis,  pupilary  rigidity,  the  demonstration  of  mor- 
phine in  the  urine  or  in  the  stomach,  and  the  numerous  scars, 


THE  INTOXICATION  PSYCHOSES  303 

boils  and  abscesses  caused  by  the  injections,  as  well  as  by  the 
symptoms  due  to  abstinence. 

3.     Cocainism 

Cocaine  was  at  one  time  employed  for  the  purpose  of  counter- 
acting the  manifestations  produced  by  morphine  abstinence. 
Thus  we  can  understand  why  the  chronic  abuse  of  cocaine  is 
usually  associated  with  morphine  addiction.  Cocaine,  however, 
constitutes  a  most  dangerous  substitute  for  morphine.  Its 
action  is  far  more  deleterious  and  malign  than  that  of  morphine 
or  alcohol,  and  it  usually  leads  to  deep-seated  mental  and  bodily 
enfeeblement. 

Cocaine  intoxication  produces  a  state  of  inebriety  similar  to 
that  caused  by  alcohol,  in  which  exalted  self-satisfaction,  pro- 
nounced euphoria  and  desire  for  activity  occupy  the  most  prom- 
inent place.  Cocaine  poisoning  is  characterized  by  the  follow- 
ing symptoms : 

(1)  Rapid,  progressive  bodily  decline.  The  patients  become 
sleepless,  greatly  emaciated,  deteriorate  more  and  more  and  ap- 
pear withered  and  senile.  The  pupils  are  widely  dilated. 
Marked  muscular  weakness,  ataxia  and  tremor  exist.  The  re- 
flexes are  exaggerated.  The  pulse  is  accelerated.  Pronounced 
sweating,  palpitation,  dyspnoea  and  attacks  of  dizziness  set  in. 
Sexual  potency  disappears.  Nutrition  and  digestion  are  at  their 
lowest. 

(2)  Associated  with  the  above  symptoms  there  develops  pro- 
nounced alteration  of  character  in  the  nature  of  a  moral  and 
intellectual  decline.  The  patients  become  loquacious,  forgetful 
and  disorderly;  the  demands  of  propriety  are  neglected.  A 
typical  feature  is  a  peculiar  sort  of  bustling  assiduity  that  mani- 
fests itself  by  a  purposeless  general  occupation  in  which  details 
are  totally  overlooked  or  neglected.  This  is  associated  with 
apathy,  complete  loss  of  will  power  and  marked  enfeeblement 
of  memory. 

Upon  this  basis  of  chronic  cocainism,  pronounced  mental  dis- 
orders are  often  developed.  Most  frequent  is  the  acute  insanity 
of  cocainists.  This  in  some  ways  resembles  delirium  tremens, 
while  in  others  it  is  like  the  acute  hallucinosis  of  drinkers.  It 
is  characterized  by  the  following  symptoms : 


304    THE  UNSOUND  MIND  AND  THE  LAW 

(1)  It  usually  sets  in  suddenly  with  sense  deceptions  that 
implicate  hearing,  sight  and  sensation.  The  patients  hear  them- 
selves threatened  and  abused,  and  have  all  kinds  of  abnormal 
sensations  in  the  skin,  such  as  itching,  pricking,  burning,  etc. 

(2)  As  in  acute  alcoholic  insanity,  so  here  the  sense  decep- 
tions are  accompanied  by  paranoiacal  delusions.  The  patients 
believe  themselves  observed,  followed  and  threatened.  They 
turn  to  the  police  for  help  or  themselves  take  up  arms  against 
their  supposed  persecutors.  Dangerous  attacks,  homicide  and 
suicide  are  not  unusual.  Often  the  paranoiacal  notions  take 
the  form  of  delusions  of  jealousy  which  manifest  themselves  in 
a  most  absurd  form.  Not  infrequently  these  also  lead  to  dan- 
gerous attacks. 

(3)  Orientation  and  outward  collectedness  usually  remain 
completely  preserved  just  as  is  the  case  in  acute  alcoholic  in- 
sanity. Hence,  the  patients  tell  their  stories  in  a  logical,  well- 
ordered  manner,  which  gives  their  delusions  an  impress  of  truth 
and  exactitude. 

The  diagnosis  of  cocainism  is  generally  derived  from  the 
anamnesis.  Nevertheless  many  morphinists  will  conceal  the  fact 
that  they  have  also  been  taking  cocaine.  It  should  be  remem- 
bered that  all  decided  psychotic  symptoms  occurring  in  mor- 
phinism (hallucinations,  paranoiac  delusions)  should  always 
arouse  the  suspicion  of  a  complication  with  alcohol  or  cocaine. 
The  acute  hallucinosis  of  cocainism  rapidly  disappears  when 
the  cocaine  is  withdrawn,  to  return,  however,  with  every  re- 
newed injection  of  the  drug. 

The  prognosis  of  cocainism  and  cocaine-morphinism  is  very 
bad.  The  bodily  and  mental  deterioration  usually  takes  an  ap- 
pallingly rapid  course,  such  as  is  not  observed  in  uncomplicated 
morphinism  or  alcoholism.  A  not  uncommon  feature  is  a  chronic 
delusional  state  that  becomes  permanently  established  after  the 
acute  hallucinosis  has  passed  off. 

There  are  still  other  narcotic  poisons  that  may  lead  to  chronic 
intoxication  and  mental  disorders  which  in  many  ways  are 
similar  to  those  just  described.  Among  these  are  ether,  chloral, 
chloroform,  hasheesh,  opium  and  absinthe. 


THE  INTOXICATION  PSYCHOSES         305 

4.    Lead  Intoxication 

Severe  psychic  disorders  often  develop  upon  the  basis  of  a 
poisoning  by  lead.  A  differentiation  may  be  made  between 
acute  and  chronic  lead  psychoses,  as  follows: 

( 1 )  The  acute  lead  psychoses  take  their  course  under  the  guise 
of  a  manic-like  excitement  or  of  a  hallucinatory  confusion  and 
almost  always  have  a  certain  similarity  to  the  twilight  states  of 
epilepsy.  Nearly  all  acute  lead  psychoses  are  accompanied  by 
sense  deceptions.  States  resembling  the  delirium  of  alcoholism 
have  also  been  observed  in  lead  poisoning.  The  numerous  physi- 
cal symptoms  of  lead  intoxication  will  serve  to  determine  the 
diagnosis.  The  prognosis  is  good,  the  duration  being  from  one 
to  two  weeks. 

(2)  In  certain  cases  upon  the  basis  of  chronic  lead  intoxica- 
tion there  are  developed  pronounced  affections  of  the  nervous 
system  that  manifest  themselves  in  states  similar  to  those  en- 
countered in  paresis.  Marked  dementia  with  numerous  symp- 
toms of  organic  lesion,  palsies  of  ocular  muscles,  neuritis  optica, 
disorders  of  speech,  pupilary  irregularities,  epileptic  attacks 
and  general  motor  weakness  may  produce  the  impression  of  a 
dementia  paralytica.  The  condition  is  generally  a  kind  of 
dream-like  confusion  or  of  drunkenness,  with  visual  hallucina- 
tions and  jumbled  notions  of  persecution. 

The  prognosis  is  always  a  serious  one,  yet  not  infrequently 
recovery  takes  place  when  the  poison  has  been  eliminated.  More 
frequent,  however,  is  a  pronounced  remission  in  which  a  certain 
mental  weakness,  as  is  the  case  in  chronic  alcoholism,  remains. 
Some  cases  end  fatally  in  a  state  of  coma. 


Part  Third 
SPECIAL  ANOMALIES 


HYPNOSIS 

The  terms  ' '  hypnosis, "  ' '  hypnotism, ' '  and  ' '  hypnotic  sugges- 
tion, "  as  employed  in  modern  psychology  and  psychopathology, 
are  based  upon  the  assumption  of  the  existence  of  a  peculiar 
psychic  manifestation  or  group  of  manifestations  which  had  pre- 
viously been  unrecognized,  or  at  any  rate  not  sufficiently 
appreciated. 

The  existence  of  such  peculiar  manifestations  is  denied  by 
some  observers,  and  therefore  they  consider  these  terms  unnec- 
essary and  misleading  and  would  have  them  banished  from 
scientific  terminology.  Moreover,  those  observers  who  maintain 
that  these  manifestations  exist  are  by  no  means  in  accord  as  to 
their  practical  forensic  significance,  and  their  opinions  differ 
particularly  on  the  question  of  whether  such  manifestations 
should  be  included  in  the  domain  of  psychology  or  in  that  of 
pathology.  For  this  reason  it  is  impossible  to  give  a  concise, 
accurate,  practical  definition  of  the  various  terms.  It  is  claimed, 
however,  that  the  respective  doctrines  of  these  observers  are  of 
primary  significance  in  juristic  medicine.  By  way  of  emphasis 
on  the  forensic  side  of  the  question  the  most  extreme  supporters 
of  these  teachings  maintain  that  it  is  possible,  by  means  of 
hypnotism,  to  influence  the  perceptions,  notions  and  feelings  of 
an  individual,  and  in  accordance  with  the  desire  of  the  hypnotist, 
to  modify  them  to  such  an  extent  that  the  individual  will  become 
a  passive  subject  of  the  hypnotist's  power  and  under  certain 
conditions  will  unhesitatingly  carry  out  his  commands. 

Instances  in  which  the  question  of  hypnotic  influence  has  re- 
ceived juristic  attention  are  as  yet  comparatively  few  in  number. 
Theoretically,  however,  the  question  may  obtrude  itself  at  any 
time  either  as  one  of  civil  or  criminal  proceedings  or  as  a  pro- 
cessual  matter.  In  a  civil  action,  for  instance,  a  party  may 
claim  to  have  been  deceived  through  hypnotic  influence  in  regard 
to  certain  objects  or  facts,  or  in  the  appreciation  of  attendant 

309 


310    THE  UNSOUND  MIND  AND  THE  LAW 

circumstances,  and  that  as  a  result  certain  legally  relevant  acts 
were  committed  or  omitted,  or,  in  a  criminal  proceeding,  the 
accused  may  claim  that  the  deed  with  which  he  is  charged  was 
committed  by  him  while  under  an  hypnotic  ban;  or  else  the 
person  who  has  been  injured  by  the  accused  may  claim  to  have 
been  influenced  hypnotically  by  the  latter  so  as  to  have  been 
unable  to  oppose  his  aggressions.  Processually  the  question  may 
arise  in  one  of  the  following  ways: 

In  civil  proceedings:  When  a  party  maintains  that  a  certain 
document  or  signature  to  a  document  has  been  obtained  by  means 
of  hypnotic  influence. 

In  criminal  proceedings:  When  an  incriminating  document 
furnished  by  the  accused  or  a  confession  is  said  to  have  been 
obtained  by  hypnotic  means. 

Common  to  both  forms  of  proceeding:  When  witnesses  or 
judges  are  said  to  have  been  unduly  influenced  by  hypnotic 
means. 

These  assumptions  even  in  the  skeletonized  form  in  which  they 
are  presented  may  appear  to  be  extreme,  but  it  cannot  be 
denied  that  they  are  logical  deductions  from  the  doctrine  of 
hypnosis.  For  this  reason  it  has  seemed  to  me  to  be  necessary 
to  enter  into  the  question  of  hypnotism  in  greater  detail.  This, 
however,  cannot  be  done  satisfactorily  without  some  knowledge 
of  its  history. 

The  predecessor  of  the  doctrine  of  hypnotism  was  the  doctrine 
of  animal  magnetism.  The  latter,  which  can  be  traced  back 
to  a  much  earlier  period  (particularly  Paracelsus  1530),  was 
elaborated  and  systematized  by  Mesmer  (died  1815).  The  salient 
note  of  his  doctrine  was  that  by  means  of  a  force  existing  in  the 
human  organism  and  susceptible  of  transmission  directly 
through  contact  or  indirectly  through  living  creatures  or  inani- 
mate objects,  one  person  could  exert  a  peculiar  influence  upon 
another.  This  influence  Mesmer  employed  for  curative  pur- 
poses. The  effect  of  such  magnetization  differed  greatly  in  dif- 
ferent individuals.  While  some  patients  became  quiet,  others 
became  excited,  and  in  still  others  convulsions,  occasionally  pre- 
ceded by  a  state  of  fatigue  and  sleep,  were  produced.  These 
convulsions  were  designated  as  crises. 

Puysegur,  a  pupil  of  Mesmer,  while  treating  a  patient  by 
means  of  mesmerism,  noticed  that  the  latter,  after  a  brief  sit- 


HYPNOSIS  311 

ting,  fell  into  a  state  of  sleep  in  which  Puysegur  was  able  to 
influence  the  man's  thoughts  and  movements.  This  state  of 
sleep  was  called  "somnambulism."  In  the  year  1819  Deleuze 
wrote  a  history  of  magnetism  in  which,  among  other  things,  we 
find  the  statement  that  an  individual  who  had  been  placed  in  a 
somnambulic  state  by  means  of  magnetism  could  recall  to  mind 
things  which  he  could  not  remember  during  his  waking  state; 
and  furthermore  that,  in  this  somnambulic  state  the  magnetized 
man  was  completely  dominated  by  the  will  of  the  magnetizer 
in  everything  except  what  was  injurious  to  himself  or  contrary 
to  his  ideas  of  truth  and  justice,  and  yet  he  might  be  led  to  do 
things  that  were  reprehensible. 

Petetin,  also  a  supporter  of  magnetism,  in  1787  described 
catalepsy.  In  1819  Faria  maintained  that  somnambulic  sleep 
could  not  be  produced  indiscriminately,  but  only  in  those  pos- 
sessing a  special  congenital  disposition.  He  contended  also  that 
the  use  of  the  term  "magnetism"  had  no  justification,  and  that 
the  inciting  factor  in  the  production  of  the  sleep  was  not  any 
magnetic  influence,  but  the  will  of  the  magnetized  person,  who 
felt  himself  under  a  compulsion  to  sleep.  Accordingly  he  also 
opposed  the  then  prevailing  method  of  sleep  production,  which 
consisted  in  laying  the  hands  upon  the  body,  stroking  the  skin, 
and  in  the  so-called  "passes"  in  which  the  hands  of  the  operator 
were  brought  parallel  to  and  at  a  certain  distance  from  the  body 
of  the  subject. 

He  treated  only  such  persons  as  seemed  to  him  to  be  amenable 
to  such  sleep  production.  His  method  consisted  in  requesting 
the  patients  to  close  their  eyes  and  then  commanding  them  to 
sleep.  Or  he  had  them  fixate  the  palm  of  one  of  his  hands,  which 
he  then  gradually  brought  closer  to  their  eyes  and,  if  necessary, 
he  supplemented  this  by  touching  certain  parts  of  the  head  and 
body.  The  occurrence  of  convulsions,  he  maintains,  was  not  due 
to  any  fault  of  the  magnetizer  but  to  the  tense  apprehensive 
restlessness  with  which  certain  individuals  anticipated  the  com- 
ing event.  Faria  also  denied  that  there  was  any  difference 
between  somnambulic  and  natural  sleep.  Deleuze  and  Faria 
have  also  observed  "sleep"  of  long  duration,  during  which  the 
individuals  fulfilled  all  their  obligations  and  in  the  intervals 
between  one  "sleep"  and  another  had  recollections  only  for 
the  occurrences  of  the  waking  period. 


312    THE  .UNSOUND  MIND  AND  THE  LAW 

In  1843  Braid  became  a  supporter  of  Faria's  theories  of  the 
dependence  of  sleep  production  upon  the  subjective  will  of  the 
patient.  He  believed  the  sleep-like  state  to  be  due  to  states  of 
fatigue,  particularly  when  brought  about  by  the  methods  that 
he  employed,  viz.,  fixation  of  a  glittering  object.  He  called  this 
state  "hypnotism."  He  made  use  of  it,  among  other  purposes, 
as  had  others  before  him,  for  the  performance  of  painless  surgi- 
cal operations.  Above  all,  he  studied  catalepsy  and  those  sug- 
gestions that  were  effectual  in  the  cataleptic  subject  by  placing 
the  limbs  or  body  in  different  postures. 

In  1856,  Azam,  following  Braid's  principles,  observed  and 
treated  a  young  girl  who  was  mentally  disordered,  hysterical 
and  subject  to  spontaneous  cataleptic  attacks  accompanied  by 
aneesthesia  and  hyperesthesias.  Through  fixation  of  his  lancet 
he  induced  sleep  and  produced  a  catalepsy,  in  which  there  ex- 
isted insensitiveness  to  pain,  followed  by  augmented  sensibility, 
and  during  which  he  was  able,  by  folding  the  hands  and  placing 
them  in  the  proper  position,  to  suggest  ideas  of  a  religious 
nature. 

Broca  paid  particular  attention  to  surgical  operations  upon 
hypnotized  persons.  With  Charcot  and  his  hypnotic  experiments 
at  the  Salpetriere  in  Paris,  a  new  impress  was  given  to  the  entire 
subject.  He  applied  himself  to  a  study  of  the  individual  phe- 
nomena that  take  place  in  the  hypnotic  state,  and  confined  his 
experiments  to  persons  suffering  from  major  hysteria.  His  pu- 
pils later  extended  the  field  of  experimentation  to  hysteria  in 
general.  In  1879  Paul  Richer  published  his  observations,  also 
made  upon  persons  afflicted  with  major  hysteria. 

Previously,  however,  in  1866,  Liebault  (later  of  Nancy)  had 
published  studies  of  suggestion  therapy.  He  oppugned  the  doc- 
trines of  animal  magnetism,  which  still  had  many  supporters. 
His  experiments  were  conducted  particularly  upon  individuals 
whom  he  considered  non-hysterical.  In  this  he  was  followed  by 
his  pupil,  Bernheim,  also  of  Nancy. 

Others  studied  hypnotism  more  particularly  from  the  so-called 
physiological  side,  and  still  others  from  the  forensic  point  of 
view. 

An  examination  of  the  constitution  of  the  doctrines  of  hyp- 
notism as  taught  to-day  will  reveal  differences  of  interpreta- 
tion so  manifold  that  a  detailed  consideration  of  them  in  the 


HYPNOSIS  313 

present  writing  would  lead  us  too  far  afield.  Nevertheless  two 
main  tendencies  must  be  specially  noted,  and  it  is  to  these  that 
we  shall  confine  our  remarks.  These  are  the  teachings  of  the 
so-called  Paris  School  of  Charcot  and  his  pupils,  and  those  of 
the  Nancy  School,  of  Liebault  and  Bernheim. 

Before  proceeding  any  further,  it  should  be  stated  in  support 
of  the  teachings  of  the  protagonists  of  hypnotism  that  they 
adduced  an  extraordinarily  large  number  of  cases  dependent 
entirely  upon  experimentation,  while  the  cases  that  have  oc- 
curred independently  of  any  experimenter  have  been  very  few, 
and  actual  medico-legal  cases,  as  previously  mentioned,  are  al- 
most entirely  lacking.  With  that  fact  in  mind,  we  may  now  take 
up  the  fundamental  traits  of  the  two  schools.  Charcot's  studies 
of  hypnotism  are  based  entirely  upon  observations  made  upon 
individuals  suffering  from  major  hysteria.  His  results  may  be 
summarized  as  follows:  The  symptom  complex  of  hypnotism  is 
made  up  of  certain  neuro-muscular  manifestations.  These  con- 
sist of  three  states,  differing  from  one  another  by  sharply  de- 
fined characteristics,  and  are  known  respectively  as  lethargy, 
catalepsy,  and  somnambulism.  The  differentiating  factor  is  the 
neuro-muscular  excitability.  Under  normal  conditions  mere 
pressure  upon  a  motor  nerve  will  cause  no  muscular  contraction, 
but  pressure  upon  a  sensory  nerve  will  produce  pain.  In  the 
hypnotic  state,  however,  pressure  upon  a  motor  nerve  will  cause 
muscular  contraction  so  pronounced  as  to  be  tetaniform.  This 
increased  excitability  is  found  in  many  hypnotizable  hysterics 
even  in  their  waking  state,  as  well  as  in  many  non-hypnotizable 
hysterics.  In  all  of  these  individuals  the  contraction  occurs  in 
grades  entirely  analogous  to  the  grades  encountered  in  the 
hypnotic  states  of  lethargy  and  catalepsy. 

It  is  unnecessary  for  our  purpose  to  enter  into  a  description 
of  these  manifestations  that  go  to  make  up  each  one  of  these 
states,  as  described  by  Charcot  and  corroborated  by  Paul  Richer, 
nor  to  mention  the  differences  of  opinion  held  by  Charcot's  fol- 
lowers in  regard  to  the  facts  pertaining  to  neuro-muscular  hyper- 
excitability.  These  differences  seem  to  be  due  to  the  fact  that 
some  of  the  investigators  made  their  experiments  upon  hysterics 
while  others  experimented  upon  healthy  individuals.  Bottey, 
rinding  an  increased  neuro-muscular  excitability  in  both  the 
healthy  and  the  sick,  concludes  that  the  hypnotic  manifestations 


314    THE  UNSOUND  MIND  AND  THE  LAW 

obtained  in  healthy  individuals  must  be  similar  to  those  that 
are  encountered  in  hysterics.  Gilles  de  la  Tourette,  on  the  other 
hand,  maintains  that  there  can  be  no  hypnosis  in  persons  who 
are  in  good  health,  and  therefore  that  hypnotized  individuals 
presenting  those  symptoms  of  disease  are  only  apparently 
healthy. 

In  addition  to  the  three  typical  states  described  by  Charcot, 
the  French  school  assumes  the  existence  of  transitional  states 
designated  as  conscious  lethargy,  ecstasy  and  fascination. 

The  doctrines  of  the  Paris  School,  briefly  expressed,  contend 
that  physically  the  hypnotized  person  is  under  the  control  of 
the  hypnotist  only  to  a  limited  extent,  but  psychically  he  is  com- 
pletely under  the  control.  The  hypnotist's  influence,  according 
to  these  investigators,  is  transmitted  by  the  aid  of  memory  stim- 
ulation produced  in  the  most  varied  ways.  The  scope  of  this 
influence  may  extend  to  the  entire  somato-physic  and  psychic 
sphere — the  special  senses,  emotions,  ideas  and  will-power. 

The  action  by  means  of  which  the  influence  is  exerted  is  tech- 
nically designated  as  "the  suggestion."  The  nature  of  this 
suggestion,  the  conditions  under  which  it  can  be  produced,  etc., 
will  next  be  considered. 

Hypnotic  suggestions,  according  to  the  time  at  which  they 
take  effect,  are  designated  respectively  as  hypnotic  and  post- 
hypnotic suggestions.  The  former  exert  their  action  solely 
during  the  actual  state  of  hypnosis  and  their  influence  termi- 
nates with  the  ending  of  the  hypnosis.  The  post-hypnotic  sug- 
gestions, on  the  other  hand,  although  of  course  inaugurated  dur- 
ing the  hypnosis,  are  not  annulled  by  the  cessation  of  the  hyp- 
notic state,  but  may  manifest  their  action  for  a  more  or  less 
protracted  period  of  time  thereafter.  To  these  two  kinds  of 
hypnotic  suggestion  a  third  must  be  added,  one  which  acts  simi- 
larly but  apparently  has  nothing  in  common  with  hypnosis 
itself.  This  is  the  suggestion  transmitted  during  the  waking 
state. 

These  three  classes  of  suggestion  may  in  turn  be  subdivided. 
The  causal  connection  between  the  objective  and  subjective  hap- 
penings, between  hypnotist  and  hypnotized,  is  governed  by  the 
following  principles,  as  formulated  by  Janet :  By  means  of  sug- 
gestion ideas  will  call  forth  ideas,  movements  will  call  forth 


HYPNOSIS  315 

movements,  ideas  will  call  forth  movements,  and  movements  will 
call  forth  ideas. 

In  considering  which  persons  are  open  to  suggestion,  we 
should  bear  in  mind  that  not  every  one  who  is  hypnotizable 
is  amenable  to  suggestion.  Moreover,  a  person  who  reacts  post- 
hypnotically  to  suggestion  is  almost  certain  to  be  suggestionable 
also  intra-hypnotically,  whereas  the  converse  proposition  would 
not  be  applicable.  Moreover,  most  individuals  who  are  sugges- 
tionable are  susceptible  only  to  suggestions  from  some  one  who 
has  placed  them  in  hypnosis,  and  they  successfully  oppose  any 
attempt  at  suggestion  made  by  other  persons.  But  they  are 
always  amenable  to  suggestions  from  a  person  who  has  hypno- 
tized them  on  a  previous  occasion,  and  to  suggestions  from  any 
one  whom  the  hypnotist  in  the  course  of  the  hypnosis  designated 
to  the  subject  as  being  capable  of  influencing  him  by  means  of 
suggestion. 

Auto-suggestion  also  may  occur ;  that  is,  a  person  may  hypno- 
tize and  suggestionize  himself.  In  this  case  we  have  an  exam- 
ple of  that  duplication  of  personality  that  is  encountered  else- 
where in  psychopathology. 

If  now,  more  particularly  from  the  viewpoint  of  intra-hyp- 
notic  suggestion,  we  ask  in  which  order  the  three  states  of  Char- 
cot are  favorable  for  suggestion,  we  will  find  the  state  of 
lethargy  to  be  the  one  that  is  least  so,  for  although  in  lethargy 
the  body  reacts  to  certain  stimuli,  psychic  activity  is,  so  to  say, 
extinct. 

In  catalepsy,  on  the  other  hand,  suggestion  finds  free  entry. 
In  this  state  it  is  above  all  the  posture  that  is  imposed  upon  the 
body  that  acts  as  a  suggestion  for  the  production  of  ideas.  Thus, 
folding  the  hands  will  arouse  religious  notions,  or  placing  cer- 
tain objects  in  the  subject's  hand  will  incite  corresponding  acts. 
Even  complicated  orders  may  be  effectively  suggested  to  certain 
cataleptics.  Wheresoever  the  suggested  command  is  executed, 
it  is  carried  out  with  machine-like  obedience. 

Of  all  three  the  somnambulic  state  offers  the  most  favorable 
basis  for  suggestion.  Nevertheless  it  is  true  even  of  this  state 
that  by  no  means  all  those  who  can  be  placed  in  a  condition 
of  hypnotic  somnambulism  are  amenable  to  suggestion  while 
in  that  condition.  However,  a  repetition  of  the  hypnosis  may 
disclose  a  suggestibility  that  has  hitherto  remained  latent. 


316    THE  .UNSOUND  MIND  AND  THE  LAW 

So  far  as  post-hypnotic  suggestion  is  concerned,  all  that  need 
be  said  is  that  all  things  which  can  be  suggested  intra-hypnoti- 
cally  can  also  be  suggested  post-hypnotically. 

Suggestion  during  the  hypnotic  states  can  bring  about  hallu- 
cinations and  sensory  deceptions  of  all  kinds  as  well  as  definite 
physical  alterations. 

Of  special  importance  are  the  suggestions  known  as  retro- 
active, for  it  is  through  them  that  a  person's  ideas  can  be  so 
influenced  that  he  will  imagine  he  recalls  a  certain  incident, 
which,  as  a  matter  of  fact,  is  purely  fictitious  and  therefore 
could  never  have  formed  part  of  the  individual's  conceptual 
store. 

Negative  suggestions  also  are  possible;  that  is,  a  person  may 
be  made  not  to  perceive  objects  or  persons  which  actually  are 
present  within  his  visual  field.  Hence  also,  it  is  possible  to  take 
from  a  person  his  recollection  of  certain  individual  incidents — 
yes,  even  of  an  entire  epoch  of  his  life. 

The  influence  of  hypnotic  suggestion  upon  the  memory  in 
general  also  requires  attention.  After  awakening  from  the  pure 
lethargic  state  the  hypnotized  individual  possesses  no  recollec- 
tion whatsoever  of  the  occurrences  that  have  taken  place,  for,  as 
Grilles  de  la  Tourette  has  fittingly  said,  during  this  state  "the 
individual  is  as  a  mass  without  mind."  Moreover,  all  observa- 
tions show  that  after  somnambulism  and  catalepsy  memory  is 
lost  for  the  happenings  of  the  hypnosis.  This  statement  applies 
also  to  post-hypnotic  suggestions,  for  although  they  are  carried 
out,  they  are  executed  without  any  recollection  for  anything 
that  refers  to  the  act  or  the  circumstances  of  the  suggestion  or 
to  the  person  of  the  suggestor.  But  the  retention  of  memory  and 
the  extent  to  which  memory  shall  be  retained  are  also  matters 
that  are  governed  by  suggestion.  On  the  other  hand,  in  a  second 
or  in  any  subsequent  hypnosis  the  individual  will  recall  all  the 
occurrences  of  the  preceding  one  and  can  then  give  information 
regarding  them.  This  eventuality  may  be  nullified  during  the 
first  hypnosis,  however,  by  suggesting  that  in  any  future  hyp- 
nosis there  shall  be  no  recollection  for  the  occurrences  that  have 
taken  place  during  the  first  one.  On  the  other  hand,  during  the 
hypnosis,  and  of  course  aside  from  the  state  of  lethargy,  the  in- 
dividual is  intensely  conscious  of  all  the  occurrences  of  his 
ordinary  life. 


HYPNOSIS  317 

Of  cardinal  significance  is  the  question  to  what  extent  the 
individuality  of  a  person  will  assert  itself  in  opposition  to  the 
hypnotic  influence.  Naturally  it  will  be  a  question  essentially 
of  the  person's  individuality  in  relation  to  his  or  her  responsi- 
bility. For  instance,  not  every  woman  who  is  hysterical  can 
be  considered  a  favorable  subject  for  hypnotism  simply  for  that 
reason.  The  point  to  be  decided  is  to  what  extent  a  person  who 
is  hypnotizable  and  has  actually  been  placed  in  a  state  of  hyp- 
nosis preserves  her  individuality  toward  hypnotic  suggestion. 
This  preservation  of  individuality  must  manifest  itself  first  in 
a  peculiar  mode  of  reacting  to  suggestion  and,  secondly,  in  op- 
posing certain  suggestions  contrary  to  the  person 's  individuality. 

As  a  matter  of  fact,  the  individual  does  not  lose  his  psychic 
individuality  during  hypnosis  except  in  the  state  of  lethargy. 
So  far  as  the  execution  of  commands  is  concerned,  these  will 
be  carried  out,  if  at  all,  entirely  as  the  person  giving  the  orders 
directs.  We  should  not  forget,  however,  that  even  in  normal 
life  no  command  can  be  given  so  unequivocally  that  the  indi- 
viduality of  the  person  executing  it  will  not  come  into  action. 
Nor  should  we  overlook  the  fact  that  each  of  two  persons  carry- 
ing out  a  certain  order  with  implicit  obedience  will,  according 
to  mental  disposition,  training  and  nature,  do  so  in  his  own 
special  way.  The  one  will  perform  a  certain  specified  action 
dexterously,  the  other  awkwardly;  the  one  rapidly,  the  other 
slowly;  and  the  more  complicated  the  command,  the  greater 
the  demand  upon  the  individual's  efficiency,  the  more  evident 
will  the  variations  become. 

All  this  applies  with  equal  force  to  the  hypnotic  state,  as 
clearly  shown  by  the  following  example :  A  girl  is  commanded 
to  poison  one  of  her  acquaintances.  She  offers  him  a  glass  of 
supposedly  poisoned  water;  he  refuses  to  drink.  Then  with  all 
her  powers  of  inventiveness  and  persuasion  she  endeavors  to 
get  him  to  do  so,  and  she  does  this  with  so  much  individuality 
and  independence  that  there  can  be  no  question  of  automatic 
obedience  on  her  part. 

Other  experiments  show  that  the  individual  who  otherwise 
obeys  implicitly  will  be  thoroughly  refractory  to  suggestions  that 
are  contrary  to  her  sense  of  morality  or  to  her  conscience,  or 
she  will  respond  only  partially  and  may  then  spontaneously 


318    THE  .UNSOUND  MIND  AND  THE  LAW 

substitute  some  act  less  offensive  to  her,  but  equivalent  to  the 
one  she  has  been  commanded  to  carry  out. 

It  will  not  be  out  of  place  here  to  give  brief  consideration 
to  those  post-hypnotic  suggestions  that  do  not  take  effect  imme- 
diately upon  awakening,  but  only  after  a  more  or  less  pro- 
tracted period  of  time.  In  such  instances  the  individual,  while 
in  a  state  of  hypnosis,  receives  an  order  with  instructions  to 
carry  it  out  only  after  a  lapse  of  a  certain  time  or  at  a  certain 
hour  on  a  future  date.  Various  successful  experiments  of  this 
nature  have  been  reported,  including  one  in  which  sixty-three 
days  elapsed  between  the  hypnosis  and  the  day  set  for  executing 
the  order. 

Finally  a  word  should  be  said  concerning  suggestion  during 
the  waking  state.  This  is  of  interest  chiefly  in  relation  to  cer- 
tain individuals  who,  more  particularly  as  a  result  of  frequent 
previous  hypnotizations,  have  become  so  impressionable  that  even 
in  their  normal  state  they  will  react  to  suggestions  of  every  kind. 
Under  the  influence  of  such  non-hypnotic  suggestions  they  will 
show  precisely  the  same  manifestations  as  are  observed  in  them 
during  the  hypnotic  state. 

The  foregoing  matter  summarizes  the  salient  teachings  of  the 
Paris  School,  and  we  may  now  return  to  those  of  the  Nancy 
School.  The  chief  theory  of  the  latter  is  that  suggestion  alone 
is  responsible  for  the  hypnosis.  "Whereas,  according  to  the  Paris 
School  a  certain  somatic  procedure  is  necessary  for  the  produc- 
tion of  a  hypnotic  state,  the  Nancy  School  maintains  that  hyp- 
nosis is  dependent  entirely  upon  psychic  influence.  Moreover, 
this  school  attaches  no  importance  whatever  to  the  somatic  symp- 
toms which,  according  to  the  Paris  School,  differentiate  the  vari- 
ous hypnotic  states.  The  Nancy  School  lays  stress  entirely  upon 
the  psychic  characteristics,  the  observations  made  by  this  school 
having  furnished  no  support  for  the  doctrine  of  neuro-muscular 
excitability.  Besides,  this  school  looks  upon  the  hypnosis  not  as 
a  pathological  state,  but  as  a  physiological  one.  It  has  conducted 
its  studies  upon  healthy  as  well  as  upon  sick  individuals,  pay- 
ing more  attention,  however,  to  the  former. 

The  classification  of  the  various  hypnotic  states  is  made  by 
the  Nancy  School  according  to  the  extent  of  the  influence  pro- 
duced. Liebault  has  differentiated  six  grades,  while  Bernheim 
has  assumed  the  existence  of  nine.     A  detailed  description  of 


HYPNOSIS  319 

these  various  grades  is  unnecessary  for  the  purpose  of  the  pres- 
ent writing.  It  will  suffice  to  state  that  for  Bernheim's  first  six 
grades  the  reduction  of  memory  for  everything  that  has  oc- 
curred during  the  hypnotic  state  is  characteristic.  Certain  sub- 
jects have  the  consciousness  of  having  slept;  others  are  in  doubt 
and  still  others  energetically  deny  having  done  so.  In  all  in- 
stances, however,  individuals  who  have  been  in  the  fourth,  fifth 
and  sixth  grades  can  be  convinced  that  they  have  been  influenced. 

All  kinds  of  transitions  from  a  state  of  light  sopor  to  most 
profound  sleep  are  met  with.  In  many  individuals  it  may  be 
assumed  with  certainty  that  the  sensorium  and  the  intelligence 
have  remained  clear  during  the  entire  period  of  the  influence: 
others  show  only  certain  symptoms  of  sleep,  or  rather,  they  are 
asleep  so  far  as  all  other  persons  are  concerned,  but  have  re- 
mained awake  in  their  relation  to  the  hypnotist  himself.  After- 
ward, also,  the  individual  often  erroneously  believes  that  he  has 
given  himself  up  to  the  influence  merely  as  a  matter  of  acqui- 
escence, while  in  some  instances  the  existence  of  simulation  is 
possible  and  cannot  be  entirely  denied. 

For  the  seventh,  eighth  and  ninth  grades  amnesia  exists  on 
awakening  and  the  hypnosis  is  indubitable.  Sometimes  the 
amnesia  is  complete,  at  other  times  it  is  limited.  In  none  of  the 
grades  need  sleep  actually  be  present;  all  phenomena  may  take 
their  course  without  it,  and  suggestion  may  be  entirely  effective 
notwithstanding  its  absence. 

In  brief,  we  may  say  that  all  hypnotic  manifestations  are  due 
to  suggestion,  conveyed  by  means  of  example,  gesture,  words, 
etc.  The  production  of  the  hypnosis  itself  is  dependent  upon 
suggestion  and  every  other  accessory,  such  as  fixation  of  the 
operator,  serves  but  to  enhance  the  suggestive  influence.  Of 
equal  dependence  upon  suggestion  are  all  acts  that  take  place 
during  the  hypnotic  state  itself,  as  well  as  the  awakening  of  the 
subject,  no  matter  how  the  latter  may  be  accomplished.  Hence 
from  the  Nancy  viewpoint,  hypnosis  may  be  defined  as  an  altered 
psychic  state  characterized  by  a  restriction  of  consciousness, 
augmented  suggestibility  and  a  certain  amenability  of  the  hyp- 
notized person's  bodily  and  mental  functions  to  the  suggestions 
of  the  hypnotist. 

We  may  now  ask  what  deductions  of  practical  value  from  a 
forensic  point  of  view  may  be  drawn  from  the  teachings  out- 


320      THE  UNSOUND  MIND  AND  THE  LAW 

lined  above.  In  arriving  at  our  own  conclusions,  of  course,  we 
cannot  afford  to  overlook  the  deductions  reached  by  the  respec- 
tive schools. 

Let  us  start  with  the  Paris  School.  As  we  have  seen,  the  in- 
vestigators of  this  school  hold  that  the  problem  of  hypnotic 
influence  can  apply  only  to  unhealthy  persons,  or  more  specifi- 
cally only  to  those  afflicted  with  hysteria.  But  as  Gilles  de  la 
Tourette  has  particularly  noted,  it  is  not  alone  a  question  of 
actual  hysteria  but  also  of  cases  in  which  hysteria,  while  not 
yet  actually  developed,  would  be  likely  to  manifest  itself  at  any 
time. 

In  what  manner,  then,  may  the  employment  of  hypnotism  in 
such  hysterical  or  hysterically  disposed  persons  be  of  forensic 
significance  ?  It  may  be  well  to  begin  with  the  question  whether 
under  certain  circumstances  the  fact  of  hypnotization  as  such 
might  not  make  the  hypnotist  civilly  and  criminally  responsible. 

The  Paris  School  starts  from  the  assumption  that  hypnosis 
is  a  pathological  state,  and  furthermore  assumes  that  the  more 
frequently  an  individual  is  placed  in  hypnosis  the  more  sus- 
ceptible will  he  become  to  future  hypnotic  influences.  It  also 
holds  that  by  hypnotization  a  previously  latent  hysteria  may  be 
converted  into  a  pronounced  hysteria,  occasionally  of  the  most 
severe  type.  This  implies  that,  by  means  of  hypnotization,  this 
pathological  state  may  be  materially  intensified,  and  the  disease 
made  markedly  worse.  There  should  be  no  doubt  that  a  physi- 
cian who  has  injured  a  person 's  health  by  means  of  unreasonable 
or  excessive  hypnotization  could  be  held  civilly  liable  or  be 
criminally  prosecuted  in  conformity  with  the  principles  that 
apply  to  other  errors  for  which  the  medical  practitioner  is  re- 
sponsible. Similar  deductions  would  apply  to  charlatans  and 
amateur  hypnotizers.  The  fact  that  the  hypnosis  may  have  been 
effected  each  time  with  the  consent  or  upon  the  request  of  the 
patient  should  not  be  entitled  to  any  consideration,  as  the  man 
who  practises  the  profession  of  medicine  is  directly  responsible 
for  proper  treatment.  These  conclusions,  however,  have  already 
been  drawn  by  Bailly  in  his  report  on  animal  magnetism  and 
its  dangers  (Paris,  1784),  and  the  Paris  School  draws  similar 
inferences. 

But  the  hypnosis  may  have  been  effected  without  the  consent 
of  the  hypnotized  person  and  against  his  will.    This  is  partieu- 


HYPNOSIS  321 

larly  possible  in  individuals  who  possess  so-called  hypnogenic 
zones — that  is,  parts  of  the  body  are  so  sensitive  that  mere  pres- 
sure upon  them  without  any  further  measures  will  produce  hyp- 
notism, a  doctrine  propounded  by  Paul  Richer,  developed  by 
Pitres  and  accepted  by  the  Paris  School.  Let  us  suppose  that 
a  physician  or  a  layman,  knowing  and  making  use  of  the  pres- 
ence of  such  hypnogenic  zones  in  a  certain  person,  places  him 
in  an  hypnotic  state  in  order  to  prevent  him  from  completing 
an  urgent  piece  of  business,  the  execution  of  which  would  be 
of  advantage  to  the  hypnotized  person,  while  it  would  be  preju- 
dicial to  the  hypnotist  or  some  one  in  whose  interest  he  is  acting. 
Under  such  conditions  should  not  civil  responsibility  be  as- 
sumed, and  should  not  criminal  prosecution  for  unlawful  depri- 
vation of  liberty  be  warranted  ?  Moreover,  we  know  that  during 
the  hypnotic  state  the  body  of  an  hypnotized  individual  may 
be  unopposedly  subject  to  physical  violence.  The  assailant  may 
be  the  hypnotizer  himself  or  a  third  person  present  during  the 
hypnosis:  this  last  mentioned  possibility,  so  far  as  I  know,  has 
not  yet  been  encountered,  but  to  me  it  seems  a  logical  deduction 
from  our  knowledge  of  certain  forms  of  the  hypnotic  state.  We 
have  seen,  for  instance,  that  in  lethargy  all  mental  activity  lies 
dormant  and  hence  all  power  of  discrimination  must  be  wanting. 
Is  it  reasonable,  therefore,  to  suppose  that  a  hypnotized  person 
will  submit  to  physical  violence  by  one  individual  and  not  by 
another?  So  long,  then,  as  the  hypnotized  person  is  in  a  state 
during  which  the  body  is  subject  to  physical  violence  by  a  third 
person,  it  must  be  true  that  he  is  unprotected  against  physical 
maltreatment.  Particularly  could  a  hypnotized  female  person 
be  violated  during  the  hypnosis,  an  assumption  that  is  fully 
accepted  by  the  Paris  School. 

The  judicial  consequences  of  such  violation  might  be  a  matter 
of  civil  proceeding,  in  so  far  as  a  demand  for  marriage  or  for 
pecuniary  indemnity  or  a  defense  against  a  suit  for  divorce 
on  account  of  adultery  could  be  based  upon  it;  or  the  questions 
involved  might  be  purely  for  settlement  in  a  criminal  court, 
which  would  have  to  decide  whether  the  attack  constituted  a 
rape  or  a  violation  of  an  insane  or  an  actually  irresponsible 
person. 

Of  the  three  states  of  Charcot  the  one  that  lends  itself  least 
to  sexual  outrages  is  the  cataleptic  state,  because  this  does  not 


322    THE  UNSOUND  MIND  AND  THE  LAW 

last  sufficiently  long  for  the  commission  of  the  assault  and  may 
easily  be  interrupted  by  convulsive  attacks  which  would  militate 
against  it.  But  aside  from  the  question  of  physical  inability 
to  resist  any  aggression  it  must  be  remembered  that  the  hypno- 
tized person  would  be  subject  in  other  ways  to  the  will  of  the 
hypnotist,  particularly  by  means  of  suggestion.  Then  her  atti- 
tude toward  the  hypnotist  would  be  not  that  of  a  lifeless  mass, 
not  that  of  an  individual  whose  body  alone  is  at  the  mercy  of  the 
hypnotist,  but  that  of  a  person  who  would  serve  him  as  a  slave 
would  his  master,  not  only  with  his  body  but  with  his  entire 
personality,  in  thought  and  in  deed.  "Where  such  subserviency 
is  present,  however,  the  hypnotic  subject's  individuality  has  not 
been  annulled ;  on  the  contrary,  the  individual 's  intellectual 
powers  are  to  a  certain  extent  decidedly  augmented.  Hence, 
provided  no  other  inhibitory  factor  were  operative,  hypnotic 
suggestion  might  find  an  unlimited  field  of  application  in  prac- 
tical life.  There  is  hardly  any  imaginable  act  of  civil  or  crimi- 
nal relevance  for  which  an  adept  hypnotist  could  not  make  use 
of  the  subject  of  his  hypnosis,  either  as  a  victim  or  as  an  accom- 
plice. A  circumstance  favorable  to  the  accomplishment  of  such 
deeds  is  the  fact  that  by  means  of  suggestion  the  subsequent 
memory  of  the  hypnotized  person  may  be  completely  abolished 
for  the  act  of  the  suggestion  and  for  the  happenings  that  at- 
tended it,  as  well  as  for  the  person  of  the  suggestor.  The  hypno- 
tized individual,  moreover,  could  be  placed  at  the  mercy  not 
only  of  the  hypnotist  himself  but  of  another  person.  In  this 
connection  the  Paris  School  emphasizes  the  fact  that  suggestion 
may  be  so  conveyed  that  the  hypnotized  individual  would  obe- 
diently follow  the  suggestions  of  certain  third  persons. 

Nevertheless,  the  actual  facts  prove  that  suggestion  occupies 
a  place  of  but  subordinate  medico-legal  importance.  How  can 
this  be  explained?  Deleuze,  referring  to  animal  magnetism,  bad 
already  made  the  statement  that  the  magnetized  individual  was 
completely  dominated  by  the  will  of  the  magnetizer  but  only 
in  so  far  as  he  would  not  be  injured  thereby  and  in  so  far  as  it 
did  not  contravene  his  notion  of  justice  and  truth.  But  he  added 
that  if  he  were  badly  led  the  subject  would  go  wrong.  Puy- 
segur  had  maintained  that  the  obedience  of  the  magnetized  per- 
son was  unlimited  only  in  so  far  as  related  to  a  command  to  do 


HYPNOSIS  323 

things  that  were  beneficial,  but  that  it  could  not  be  used  for  other 
purposes,  even  not  for  things  that  were  quite  inoffensive. 

The  factor  then,  which  above  all  others,  according  to  the 
notion  of  the  Paris  School,  opposes  the  practical  employment  of 
hypnotism  for  illicit  purposes  is  the  opposition  involuntarily 
exerted  by  the  hypnotized  individual  towards  certain  sugges- 
tions, an  opposition  that  manifests  itself  particularly  in  the 
somnambulic  state.  This  opposition  may  be  of  only  relative 
force,  so  that  in  time  it  may  be  overcome  by  the  efforts  of  the 
suggestor,  or  it  may  be  absolute,  so  that  it  will  permanently 
withstand  all  the  operator's  endeavors.  The  correctness  of  this 
statement  may  easily  be  corroborated  by  experimentation.  Thus 
Fere  recounts  the  history  of  a  girl  who  proved  herself  amenable 
to  suggestions  of  all  kinds,  except  for  acts  likely  to  injure  her 
lover :  Pitres  tells  of  a  girl  who  followed  the  suggestion  to  steal 
but  at  once  put  the  stolen  piece  of  money  back  in  the  place  from 
which  she  had  taken  it,  with  the  remark  that  this  was  a  theft  and 
she  was  no  thief.  Pitres  also  reports  cases  of  passive  opposition 
to  unsympathetic,  post-hypnotic  suggestion,  the  individuals  not 
allowing  themselves  to  be  awakened  from  the  hypnosis,  so  long 
as  the  particular  order  was  maintained,  but  promptly  coming 
out  of  the  hypnosis  as  soon  as  the  order  had  been  retracted. 
From  such  observations,  the  conclusion  has  been  drawn  that 
the  individual  who  carries  out  a  hypnotic  suggestion  is  not, 
merely  because  he  has  been  in  a  state  of  hypnosis,  unreservedly 
absolved  from  responsibility. 

Little  practical  significance  therefore  can  be  attached  to  the 
influence  of  hypnotic  suggestion  in  cases  of  criminal  nature, 
because  hypnotism  furnishes  but  an  insufficient  guarantee  that 
the  command  will  be  executed  and  because  any  slight  miscalcu- 
lation or  the  occurrence  of  unforeseen  circumstances  would 
easily  produce  complications  that  would  endanger  the  immunity 
of  the  suggestor  against  discovery.  These  are  practical  delibera- 
tions which  would  lead  any  one  who  plans  to  commit  a  crime 
to  select  some  other  means  of  execution  than  that  of  hypnosis. 
From  a  civil  point  of  view,  however,  in  consequence  of  experi- 
ments that  have  been  made,  it  has  been  assumed  that  by  means 
of  intra-  or  post-hypnotic  suggestion  a  person  may  be  led  to 
execute  promissory  notes,  orders  for  merchandise,  etc.,  all  in 
proper  form. 


324    THE  UNSOUND  MIND  AND  THE  LAW 

In  so  far  as  concerns  the  civil  liability  and  criminal  respon- 
sibility for  acts  and  omissions  ascribed  to  hypnotized  individuals, 
we  have  seen  that  the  Paris  School  expresses  itself  with  very 
great  reserve.  Since  this  school  considers  it  experimentally 
proven  that  one  and  the  same  individual  may  possess  ample 
moral  powers  of  resistance  to  certain  criminal  suggestions,  while 
accepting  other  harmless  suggestions,  the  conclusion  has  been 
drawn  that  notwithstanding  the  proof  of  hypnotic  influence, 
there  may  in  each  individual  instance  still  exist  a  well-founded 
doubt  whether  the  person  had  not  succumbed  to  the  influence 
before  his  power  of  resistance  had  actually  been  exhausted,  in 
other  words,  whether  the  person  could  not  in  reality  have  with- 
stood the  influence  if  he  had  actually  desired  to  do  so.  From 
such  a  point  of  view  it  would  appear  self-evident  that  no  rules 
can  be  given  that  would  be  generally  applicable  to  the  annul- 
ment of  responsibility  in  consequence  of  hypnotism,  but  that 
it  must  always  be  a  question  of  the  broad  consideration  of  the 
circumstances  in  each  individual  case.  This,  however,  would  be 
exactly  the  same  standpoint  that  must  be  taken  in  all  other 
abnormal  mental  states.  According  to  the  Paris  School,  how- 
ever, hypnotic  states  are  nothing  else  than  peculiar  forms  of 
manifestation  of  hysteria,  and  therefore  what  is  applicable  to  the 
latter  in  regard  to  responsibility  would  also  be  applicable  to 
hypnosis.  If  this  be  true,  as  relates  to  questions  of  criminal 
law,  it  must  also,  with  appropriate  modifications,  be  true  for 
questions  of  civil  law. 

Let  us  now  consider  how  and  with  what  amount  of  certainty 
it  may  be  determined  in  any  particular  civil  or  criminal  case 
whether  a  state  of  hypnosis  has  been  present.  This  problem  is 
solved  by  the  Paris  School  entirely  by  the  presence  or  absence 
of  the  somatic  symptoms  of  which  we  have  spoken  in  our  sketch 
of  hypnotic  manifestations,  for  it  does  not  admit  that  the  as- 
sumption of  the  existence  of  an  hypnosis  may  be  based  upon 
purely  psychic  symptoms.  It  would  therefore  be  necessary  in 
every  case  to  investigate  whether,  how  far,  with  what  effect  and 
under  which  circumstances  the  particular  individual  is  amenable 
to  hypnotism  and  to  hypnotic  suggestion,  and  then  upon  a  basis 
of  these  results  to  determine  whether  a  hypnotic  explanation  is 
required,  or  at  any  rate  permitted,  by  the  fact  upon  which  the 
legal  contest  rests. 


HYPNOSIS  325 

How  the  expert  is  to  arrive  at  a  satisfactory  opinion  without 
himself  subjecting  the  individual  to  hypnotic  experimentation 
cannot  be  easily  understood,  however,  and  the  results  of  such 
experimental  examination  will  be  all  the  more  pronounced  the 
more  frequently  the  individual  has  been  hypnotized  in  the  past. 
Under  all  circumstances,  we  must  remember  that  hypnosis  as 
well  as  hysteria  manifests  itself  differently  in  different  indi- 
viduals; that  the  two  may  be  different  in  form  in  one  and  the 
same  individual  at  different  times ;  and  finally  that  even  excellent 
hypnotic  subjects  may  occasionally  prove  completely  refractory 
to  hypnotic  influence.  Consequently  no  clear-cut,  logical  con- 
clusion can  be  drawn ;  and  a  great  difference  exists  between  the 
experiment  in  the  laboratory  and  those  experiences  which  are 
actually  encountered  and  which  may  constitute  the  cause  for 
medico-legal  investigation. 

The  fact  that  after  a  hypnotic  state  an  individual  no  longer 
remembers  the  things  that  have  taken  place  during  the  hypnotic 
state,  and  particularly  not  when  in  the  course  of  the  hypnosis  a 
loss  of  memory  has  been  suggested  to  him,  requires  special 
consideration  at  this  place.  While  this  circumstance  would 
seem  to  favor  the  use  of  hypnotism  for  unworthy  purposes,  we 
know  that  during  a  subsequent  hypnosis,  recollection  returns 
for  the  proceedings  of  a  former  hypnosis.  Exceptions  to  the 
latter  rule  will  occur  when  during  the  first  hypnosis  the  sug- 
gestion has  been  conveyed  that  the  recollection  of  the  happenings 
of  that  hypnosis  should  be  obliterated  for  the  next  and  every 
following  hypnosis,  and  when  during  a  second  hypnosis  it  is 
sought  to  obtain  information  which  would  entail  a  confession 
distressing  to  the  hypnotized  individual;  in  the  latter  case  the 
resistance  to  unsympathetic  suggestions  of  which  we  have  pre- 
viously spoken  would  come  into  action  and  would  controvert 
any  attempt  to  obtain  knowledge  by  hypnotic  means.  But  aside 
from  these  eventualities  there  will  always  exist  the  possibility 
that  by  means  of  a  second  hypnosis  information  may  be  obtained 
in  regard  to  the  procedures  of  the  first.  "Why  not  utilize  this 
possibility  if  in  any  civil  or  criminal  procedure  there  is  a  sup- 
position that  hypnotism  or  hypnotic  suggestion  had  played  a 
part?  In  other  words,  why  should  we  rest  content  merely  with 
an  expert  opinion  concerning  the  conditions  that  may  have 
obtained  and  the  manner  in  which  the  individual  would  react  to 


326    THE  UNSOUND  MIND  AND  THE  LAW 

hypnotism  when,  by  going  a  step  farther,  we  could  establish  a 
hypnotic  state  and  thus  obtain  definite  declarations  from  the 
person  in  question  and  make  of  him  not  a  puzzle  for  expert 
opinion,  but  a  witness  in  his  own  behalf,  or  in  behalf  of  another 
person,  as  the  case  may  be  ? 

The  answer  to  this  question  can  be  given  only  in  each  par- 
ticular case,  and  the  reasons  for  opposing  such  procedure  may 
be  medical  or  legal  ones.  The  legal  objections  lie  beyond  my 
province  to  discuss.  The  most  important  of  the  medical  reasons 
is  the  objection  that,  according  to  the  Paris  School,  the  hypno- 
tizable  individual  is  an  hysteric  and  every  hysteric  possesses  an 
inherent  tendency  to  deceive  himself  and  others.  Moreover,  by 
the  same  teachings,  hysteria  is  an  acknowledged  mental  anomaly, 
hypnosis  nothing  else  than  an  existing  hysteria  that  has  been 
artificially  aroused  from  its  dormant  state  or  artificially  intensi- 
fied, and  hence  hypnosis  also  is  a  mental  anomaly.  Statements 
which  may  be  made  under  such  conditions  can  never  be  of  more 
than  subordinate  value. 

The  practical  deductions  to  be  drawn  from  the  doctrines  of 
the  Nancy  School  in  so  far  as  they  differ  from  the  teachings  of 
Charcot  are  as  follows: 

Since  the  Nancy  School  tells  us  that  hypnosis  is  not  a  mani- 
festation of  disease,  and  moreover  lays  stress  not  upon  the 
somatic  but  upon  the  psychic  symptoms,  maintaining  that  the 
hypnosis  itself  is  dependent  not  upon  somatic  manipulations  but 
essentially  upon  psychic  procedures,  we  must  conclude  that  in- 
dividuals who  are  in  perfect  mental  health  may  be  subjected 
to  hypnotic  influences  and  thus  be  made  the  objects  or  the  ac- 
complices of  every  relevant  kind  of  civil  or  criminal  misuse. 
This  is  a  deduction  that  has  been  expressly  drawn  by  the  Nancy 
School.  But,  according  to  Bernheim,  an  unusually  large  number 
of  variations  in  the  degree  of  hypnotic  influence  is  possible,  so 
we  must  conclude  that  only  in  each  individual  case  can  an  opin- 
ion be  expressed  as  to  whether  the  influence  exerted  is  one  that 
the  individual  could  oppose  or  not.  Inasmuch,  however,  as  the 
determining  symptoms  are  solely  of  psychic  nature,  it  must  in 
the  long  run  inevitably  be  a  question  of  the  individual's  entire 
personality  and  no  one  but  a  physician  who  has  had  wide  per- 
sonal experience  in  the  domain  of  hypnotism  will  be  competent 
to  give  an  opinion.     But  even  in  its  lightest  grade  hypnotiza- 


HYPNOSIS  327 

tion,  according  to  the  Nancy  School,  always  signifies  an  impli- 
cation of  the  psychic  personality,  especially  in  the  direction  of 
freedom  of  the  will,  and  for  that  reason  of  the  moral  respon- 
sibility as  well ;  and  therefore  we  cannot  see  how  the  question  of 
the  judicial  employment  of  Irypnosis  or  hypnotic  suggestion  can 
be  determined  in  any  other  way  than  that  indicated  in  our  con- 
sideration of  the  views  of  the  Paris  School.  In  all  the  differences 
that  exist  between  the  teachings  of  the  Paris  School  and  those 
of  the  Nancy  School,  the  main  questions  will  always  be  whether 
hypnotism  is  possible  solely  in  psychically  abnormal  individuals 
or  whether  it  can  also  be  effected  in  those  who  are  psychically 
normal,  and  whether  the  hypnotic  states  receive  their  decisive 
characteristics  from  somatic  or  from  psychic  symptoms. 

There  are  scientists,  however,  who  deny  that  hypnosis  pos- 
sesses any  special  characteristic  symptomatology  and  who  for 
this  reason  do  not  believe  this  state  is  deserving  of  any  special 
scientific  attention.  They  argue  that  the  manifestations  of  the 
hypnotism  of  the  Charcot  School  are  essentially  those  of  hys- 
teria and,  therefore,  deserve  no  individual  consideration,  while 
the  manifestations  studied  by  the  Nancy  School  are  essentially 
those  brought  about  by  suggestion  and  suggestion  is  an  im- 
portant factor  upon  every  domain  of  practical  life,  has  always 
been  known  and  employed,  and,  therefore,  does  not  merit  being 
specially  designated  as  hypnosis.  In  our  opinion  the  last  word 
has  by  no  means  been  spoken  concerning  the  entire  question  of 
hypnotism.  Notwithstanding  all  the  assiduity  devoted  to  the 
study  of  this  subject,  many  points  still  require  elucidation,  and 
it  seems  to  us  to  be  more  conscientious  to  answer  them  with  a 
non-liquet  than  simply  to  dismiss  them  as  absurd. 


II 

THE  ANOMALIES  OF  SEXUAL  SENSE 

Upon  the  copulative  act  depends,  anthropologically,  the  main- 
tenance of  the  race,  and,  sociologically,  the  maintenance  of  so- 
ciety. This  act  is  incited  by  the  sexual  impulse  that  is  innate 
in  every  human  being  and  which  is  not  surpassed  in  force  by 
any  other  animal  instinct.  For  this  reason,  its  psychic  correla- 
tive, love,  occupies  a  foremost  place  among  the  factors  of  emo- 
tional life. 

The  sexual  impulse  is  opposed  by  inhibitory  factors,  in  part 
dependent,  in  part  not  dependent  upon  the  human  will.  Through 
his  will  man  possesses  the  power  to  regulate  his  impulses,  of 
course,  including  the  impulse  to  sexual  intercourse. 

The  considerations  that  may  determine  an  individual  to  con- 
fine his  sexual  impulse  within  certain  bounds  may  be  of  various 
kinds,  and  among  them  will  be  those  bearing  upon  the  fact  that 
each  person  is  but  a  link  in  the  social  organism,  which  can  exist 
or  flourish  only  if  each  individual  exercises  self-control. 

The  standards  of  such  social  organism  find  their  expression  in 
custom.  Wheresoever  a  certain  social  group  is  lawfully  organ- 
ized, it  represents  a  State  and  its  standards  become  law.  Then 
the  ideal  relation  is  that,  through  its  authority,  the  State  shall 
sanction  the  condition  under  which  Society  exists.  Society  is 
left  free,  through  its  coercive  power,  to  secure  itself  against  the 
arbitrary  acts  of  its  individual  members  or  of  its  various  classes. 

Inasmuch  as  the  requirements  of  society  and  its  views  re- 
garding them  change  with  the  progress  of  culture,  as  well  as 
with  alterations  in  climatic  and  other  conditions  of  life,  it  may 
well  happen  that,  while  the  law  of  the  State  and  the  process  of 
moral  development  progress  each  in  their  own  way,  the  law  at 
certain  times  will  regard  conduct  that  is  not  anti-social  as 
deprecable,  or,  on  the  contrary,  may  regard  conduct  that  is 
anti-social  as  not  unlawful.  Such  discrepancies  may  be  encoun- 
tered when  the  law — as  is  the  case  in  the  early  beginnings  of 

328 


THE  ANOMALIES  OF  SEXUAL  SENSE    329 

culture — has  not  yet  been  formulated  in  statutes  but  is  the  prod- 
uct of  custom,  in  which  case  it  will  naturally  be  a  reflection  of 
social  opinion. 

On  the  other  hand,  at  an  advanced  stage  of  culture  the  danger 
of  discrepancy  will  become  imminent  when  certain  branches  of 
science  develop  rapidly  or  when  even  the  masses  of  the  people 
have  become  impregnated  with  newer  conceptions  that  are  con- 
trary to  old  views,  but  when  on  account  of  a  certain  conservatism 
the  old  transmitted  law  dare  not  as  yet  be  correspondingly 
altered. 

Society  is  based  upon  the  family.  As  far  back  as  history 
takes  us  the  family-forming  sexual  act  has  been  a  privileged 
one — that  is,  marital  procreation,  as  opposed  to  propagation 
outside  of  wedlock,  has  been  given  certain  parental  and  pro- 
genic  rights,  while  sexual  intercourse  of  a  third  person  with 
one  of  the  married  parties  has  been  punitively  reprehended. 
Later  non-marital  coitus  was  viewed  as  something  deprecable, 
and  here  and  there  even  as  punishable.  The  employment  of 
force  in  order  to  effect  sexual  intercourse  becomes  a  punishable 
offense,  as  also  does  copulation  with  persons  under  a  certain 
age,  etc. 

Such  elementary  regulations,  however,  no  longer  sufficed  as 
time  progressed.  Society  began  to  recognize  extreme  incest — 
copulation  between  close  relations — as  reprehensible,  and  later 
as  a  punishable  offense.  It  is  probable  that  hygienic  as  well  as 
religious  and  general  moral  principles  exerted  a  determining 
influence  in  the  establishment  of  these  views. 

The  more  fixed  the  moral  principles  of  the  individual  be- 
came, and  the  more  the  mass  of  the  people  arose  above  the 
utilitarian  standpoint  and  looked  upon  themselves  as  the 
guardians  of  moral  obligations,  the  more  decidedly  did  it  seem 
necessary  for  the  State  to  reprehend  certain  sexual  acts  which 
represented  neither  an  aggression  against  the  individual  or  the 
family  nor  a  menace  to  the  race,  but  in  other  ways  appeared 
immoral.  That  sexual  intercourse  with  animals  and  copulative 
procedures  between  individuals  of  the  same  sex  became  crimes 
showed  that  the  mass  of  the  people  recognized  such  unnatural 
satisfaction  of  sensual  desire  as  a  vice  which  dared  not  be  sanc- 
tioned if  their  own  moral  existence  was  not  to  be  imperiled. 

The  relation  that  sexually  correct  conduct  bears  to  healthy 


330    THE  UNSOUND  MIND  AND  THE  LAW 

social  conditions  is  well  shown  by  the  term  "morality"  as  gen- 
erally and  preeminently  applied  to  designate  a  respectable 
measure  of- self-control  in  one's  sexual  relations. 

Since  all  time  the  judicial  appraisal  of  sexual  delicts  has  been 
governed  almost  exclusively  by  the  objective  conditions,  with- 
out considering  in  any  way  whether  the  reprehensible  act  may 
not  have  been  the  result  of  a  diseased  state  of  mind.  A  change 
in  views  could  be  expected  only  when  psycho-pathology  had  ob- 
tained a  certain  degree  of  development.  But  even  when  this 
came  about,  the  forensic  evaluation  of  sexual  delicts  remained 
unaltered,  because  medical  science  bestowed  but  little  attention 
upon  the  anomalies  of  the  sexual  sphere,  always  seeing  only 
what  lay  on  the  surface,  viz.,  the  act  itself,  but  never  going 
deeper  in  order  to  investigate  the  underlying  causes.  The  courts 
could  not  take  the  initiative  where  the  medical  teachings  were 
remiss. 

During  the  last  decades,  however,  as  a  result  of  and  through 
the  efforts  of  William  A.  Hammond,  Kiernan  and  Lydston  in 
the  United  States,  and  of  Krafft-Ebing,  Moll  and  Schrenck- 
Notzing  abroad,  the  anomalies  of  sexual  sense  have  become  the 
object  of  marked  psycho-pathological  attention  The  results  of 
these  investigations  teach  us  that  many  instances  of  sexual  con- 
travention require  pathological  and  not  criminal  consideration. 
These  investigations  are  by  no  means  closed  and  their  literature 
is  growing  more  and  more  extended;  there  are  even  signs  of  a 
tendency  to  go  to  the  opposite  extreme  and  to  assume  disease 
where  only  culpability  exists.  All  in  all,  however,  society  has 
for  the  most  part  remained  undisturbedly  conservative  and 
everywhere  characterizes  sexual  contraventions  as  vice.  This 
may  also  be  said  regarding  our  laws  and  law  makers;  and  yet, 
as  will  be  shown,  the  anomalies  of  sexual  sense  not  infrequently 
lead  to  offenses  that  must  not  formally  be  looked  upon  as  sexual 
crimes.  In  speaking  of  the  anomalies  of  the  sexual  impulse  or 
sexual  sense  we  should  remember  that  this  impulse,  which  since 
Hegar  is  commonly  divided  into  a  copulative  and  a  propaga- 
tional  one,  in  our  present  state  of  culture — unless  it  be  in 
woman — hardly  exists  in  its  quality  of  an  impulse.  Reflection 
and  ultilitarian  considerations  have  so  held  it  in  abeyance  that 
the  only  component  with  which  we  to-day  have  to  deal  is  the 
copulative  desire. 


THE  ANOMALIES  OF  SEXUAL  SENSE     331 

This  desire  may  be  excited  by  bodily  or  mental  stimuli  and  it 
should  always  be  remembered  that  in  normal  individuals,  both 
male  and  female,  these  two  factors  can  be  separated,  if  at  all, 
only  with  the  greatest  difficulty. 

The  assertion  made  by  many  writers,  and  particularly  by 
Lombroso,  that  women  have  less  sexual  feeling  than  men  is  by 
no  means  proven.  "While  complete  lack  of  sexual  feeling  un- 
doubtedly does  occur  in  women,  this  is  often  a  result  of  errors  of 
training  and  the  artificial  life  imposed  by  certain  notions  of 
culture.  Under  normal  conditions  it  is  doubtful  whether  women 
are  sexually  any  less  excitable  than  men. 

Before  proceeding  to  a  description  of  the  individual  anomalies 
of  the  sexual  impulse  it  will  not  be  out  of  place  again  to  ex- 
plain that  not  all  that  is  anomalous  need  for  that  reason  be 
pathological,  and  that  within  the  confines  of  health,  deviations 
and  variations  from  the  normal  occur  everywhere,  so  that  due 
consideration  must  always  be  had,  even  in  the  sexual  field,  for 
individual  peculiarities.  Where  the  "anomalies"  are  to  be  con- 
sidered pathological,  a  connection  between  them  and  some  dis- 
turbance of  cerebral  function  will  have  to  be  shown ;  for  only 
after  that  has  been  done  can  an  anomaly  of  sexual  sense  be 
looked  upon  as  a  manifestation  of  mental  disease,  as  an  insanity 
in  its  technical  sense.  The  presence  of  a  psychopathy  by  no 
means  signifies  that  a  coexisting  sexual  anomaly  is  necessarily 
dependent  upon  disease.  A  paranoiac  may  acquire  and  culti- 
vate a  vice  just  as  well  as  a  person  of  sound  mind. 

There  exists  no  entirely  satisfactory  classification  of  the 
various  sexual  perversions.  Most  recently  Hoche,  Ziehen  and 
Raecke  have  emphasized  the  inadequacy  of  the  classifications 
previously  employed,  which  took  for  their  basis  the  objects  to 
which  the  anomaly  in  question  was  directed  (homo-sexuality, 
Sadism,  masochism,  etc.)  ;  and  instead  of  these  proposed  a  di- 
vision into  anhedonias,  hyperhedonias  and  parahedonias,  all  of 
which  may  be  constitutional,  may  be  associatively  implanted  or 
may  arise  compensatorily. 

While  we  admit  fully  the  need  for  the  change  advocated,  we 
retain  the  nomenclature  employed  by  the  older  writers,  particu- 
larly by  Westphal  and  Krafft-Ebing,  as  the  one  best  adapted  to 
the  purposes  of  the  present  writing. 


332    THE  UNSOUND  MIND  AND  THE  LAW 

1.    Sexual  Paradoxy  (Anachronistic  Anomalies) 

Let  us  begin  our  consideration  of  the  individual  anomalies  by 
a  description  of  those  manifestations  of  sexual  impulse  that  are 
abnormal  in  so  far  as  they  are  anachronistic — that  is,  they  occur 
at  a  time  when,  in  consequence  of  the  then  existing  anatomic 
phj'siologic  conditions,  no  such  manifestations  should  be  present. 
The  anomalies  thus  designated  are  those  that  occur  in  childhood 
and  in  senility. 

Wheresoever  in  childhood  local  sexual  desire  manifests  itself 
without  any  preceding  peripheral  irritation,  there  must  always 
be  a  suspicion  of  some  neuro-psychic  disorder.  Of  course  other 
proofs  must  be  furnished  in  each  individual  instance  before  a 
diagnosis  can  be  made,  for  the  physiological  limits  within  which 
such  desires  should  arise  are  very  wide,  much  more  so  than  was 
formerly  supposed  to  be  the  case.  Physical  and  psychic  mani- 
festations of  the  sexual  impulse,  aside  from  the  sexual  desire 
that  is  localized  in  the  genitals,  do  occur  in  healthy  children  and 
are  by  no  means  so  infrequent  as  to  be  considered  abnormal. 
Where  such  manifestations  set  in  around  the  tenth  year  of  life 
there  need  be  no  question  of  any  pathological  import,  but  it  is 
doubtful  whether  this  statement  could  apply  to  similar  manifes- 
tations occurring  at  the  age  of  five  or  six. 

Similarly  there  is  no  definite  period  in  old  age  at  which  the 
sexual  desire  ceases  to  exist.  This  does  not  apply  only  to  men, 
for  in  women,  too,  the  sexual  impulse  does  not  pass  away  with 
the  onset  of  the  menopause  and  sexual  desire  may  persist  to  an 
advanced  age.  Hence,  in  both  sexes,  sexual  excesses  may  not  be 
looked  upon  as  pathological  manifestations  merely  because  they 
occur  at  an  advanced  period  of  life.  When,  however,  after  hav- 
ing been  extinct,  and  particularly  in  the  presence  of  accentuated 
decrepitude,  the  impulse  suddenly  reappears  in  force,  this  fact 
may  be  considered  evidence  of  the  existence  of  disease  of  the 
central  nervous  system  and  it  will  then  usually  be  a  question  of 
pre-senile  or  senile  dementia. 

2.     Quantitative  Anomalies 

In  considering  the  quantitative  anomalies  we  should  bear  in 
mind  that  the  intensity  of  sexual  desire  and  sexual  needs  will 


THE  ANOMALIES  OF  SEXUAL  SENSE    333 

vary  greatly  within  the  confines  of  perfect  health  in  different 
persons,  according  to  their  individuality,  age,  constitution,  tem- 
perament and  mode  of  life,  according  to  climatic  and  other  con- 
ditions of  nature  and  according  to  social  surroundings.  Withal 
we  should  not  forget  that  anomalies,  just  because  they  are 
anomalies,  do  not  indicate  the  existence  of  disease. 

Turning  then  to  the  abnormal  increase  of  the  sexual  impulse, 
we  must  ask,  Where  does  this  increase  begin  to  be  pathological  ? 
All  observers  are  agreed  that  it  is  most  difficult  to  determine 
the  borderline  in  each  case  inasmuch  as  the  physiological  and 
pathological  demarcations  of  the  various  forms  shade  one  into 
the  other.  Even  the  theoretical  boundaries  established  by  writ- 
ers upon  the  subject  have  not  always  been  sufficiently  precise. 
I  for  my  part  believe  that  augmented  excitation  of  the  nerve 
centers  through  peripheral  stimuli,  a  state  of  increased  irritabil- 
ity of  the  centers  themselves,  as  well  as  the  local  neuroses  of  the 
genital  sphere,  are  neither  sufficient  nor  necessary  to  character- 
ize an  anomaly  as  pathological.  In  my  estimation  it  is  entirely 
a  question  of  the  abnormally  intense  or  abnormally  frequent 
excitation  that  is  conducted  from  the  brain  to  the  spinal  centers 
or  of  an  abnormal  reduction  of  inhibition  of  excitation  stimuli. 
This  view  is  also  that  of  Casper-Liman,  Tarnowsky,  Krafft-Ebing 
and  Eulenburg.  The  state  thus  defined  has  been  generally  desig- 
nated as  "sexual  hypereesthesia, "  a  form  which  Eulenburg  con- 
siders misleading  and  for  which  he  would,  therefore,  substitute 
that  of  "  hypererosia, "  or  "  hyperlagnia. "  The  not  entirely 
acceptable  terms  "erotomania"  and  "aidomania"  have  also  been 
much  employed  in  this  connection.  When  applied  to  the  male 
sex  the  term  ' '  satyriasis ' '  is  common ;  when  applied  to  the  female 
sex  "nymphomania"  is  generally  used. 

Frequently  this  augmented  impulse  will  be  found  implanted 
upon  an  epileptic  or  some  other  neurotic  degenerative  basis.  It 
may  exist  as  a  permanent  state,  or  may  occur  periodically  or  as 
an  episode  of  some  other  condition,  and  may  be  associated  with 
a  clouding  of  consciousness.  It  may  occur  with  unconquerable 
violence  and  may  then  lead  to  rape  or  other  sexual  or  non-sexual 
excesses.  Its  episodic  occurrence  may  take  place  in  epileptics  as 
an  equivalent  of  an  attack,  or  in  mania,  in  the  manic  phase  of  a 
manic  depressive  psychosis,  in  dementia  paralytica,  or  in  dis- 
order after  injury  to  the  head,  as  well  as  in  idiocy.    Chronically 


334    THE  UNSOUND  MIND  AND  THE  LAW 

it  occurs  in  some  of  the  states  we  have  mentioned,  as  well  as  in 
exhaustion  after  excesses.  In  the  latter  instance  it  is  often  ac- 
companied by  priapism,  and  will  manifest  itself  in  coitus  equiva- 
lents. In  woman  the  nature  of  this  impulse  is  similar  to  that  in 
man,  from  which  it  differs  only  in  some  manifestations  due  to 
the  existing  variance  in  conditions.  Analogous  to  hypererosia  as 
regards  its  nature  and  causes  is  the  reverse  anomaly,  the  patho- 
logical diminution  of  the  sexual  impulse,  "anaesthesia  sexualis," 
"hyperosia"  or  "hypolagnia."  This  is  dependent  upon  con- 
genital defects  or  upon  an  acquired  pathologically  diminished 
brain  function.  Usually  its  basis  is  hereditary  degeneracy,  or 
functional  or  organic  brain  disease.  Its  forensic  significance 
may  lie  within  the  domain  of  civil  law,  as  for  instance  a  non- 
compliance with  the  debitum  conjugate,  or  within  the  domain 
of  criminal  law,  when  it  leads  to  non-sexual  crimes  rather  than 
to  those  that  bear  a  manifest  sexual  impress. 

3.    Qualitative  Anomalies 

Turning  from  the  quantitative  anomalies  of  sexual  sense  to 
the  qualitative  ones  we  enter  upon  the  field  of  the  so-called 
sexual  perversions,  " paresthesia  sexualis"  or  "parerosia."  Their 
varieties  are  legion  and  they  are  in  part  apparently  so  different 
from  the  manifestations  of  the  normal  propagational  impulse 
that  it  must  be  doubtful  whether  the  term  ' '  anomaly ' '  as  applied 
to  them  is  at  all  fitting.  Hence,  the  designation  "aberration" 
seems  to  me  to  be  a  more  descriptive  one. 

"While  the  normal  sexual  impulse  tends  toward  a  junction  of 
the  male  and  female  sexual  parts,  in  many  of  the  aberrations  to 
which  we  now  refer  the  sexual  organs  as  such  play  no  part  what- 
ever. Thus  may  be  explained  the  extraordinary  statement  that 
has  crept  into  literature  that  there  exists  a  sexual  desire  which 
is  entirely  independent  of  the  sexual  organs. 

No  matter  how  extreme  these  aberrations  may  be,  they  are  all 
distortions  of  a  normal  impulse.  Forensically  their  practical 
import  is  essentially,  even  if  not  exclusively,  of  a  criminal  nature. 
Civilly  such  aberrations  have  been  of  importance  only  in  relation 
to  suits  for  divorce,  although  other  bearings  may  well  be  imag- 
ined.   Thus  it  might  well  happen  that  a  person  who  is  the  sexual 


THE  ANOMALIES  OF  SEXUAL  SENSE    335 

slave  of  another  might  make  gifts  of  such  importance  that  a  legal 
contest  for  their  recovery  would  seem  proper. 

The  various  perversions  may  be  classified  according  to  certain 
main  types,  but  these  cross  one  another  theoretically  as  well  as 
practically.  It,  therefore,  seems  well  to  me  to  divide  the  ma- 
terial at  our  disposal  so  as  to  cover  the  question  whether  the 
basis  of  the  attraction  is  between  man  and  woman  or  between 
persons  of  one  and  the  same  sex. 

A.      HETEROSEXUAL    ANOMALIES 

In  the  heterosexual  anomalies  it  is  true  the  inclination  is 
toward  the  opposite  sex,  but  at  the  same  time  it  is  markedly 
modified  by  various  intercurrent  anomalies.  Of  these  the  fol- 
lowing may  be  differentiated : 

(1)  Coitus  associated  with  such  non-essential  acts  as  appear 
subjectively  to  be  essential  lust-producing  factors. 

(2)  Coitus-like  acts. 

(3)  Sexual  symbolism,  in  which  the  lust  is  dependent  upon  a 
symbol. 

(4)  Algolagnia,  in  which  the  lust  is  produced  essentially  by 
some  act  of  cruelty. 

This  classification  does  not  include  an  abnormal  manifesta- 
tion which  is  actually  encountered  as  an  individual  type,  but 
which  may  be  looked  upon  as  an  independent  type  of  disease,  a 
"perversion"  or  essentially  as  a  type  of  vice  dependent  upon 
' '  perversity. ' '  I  refer  to  the  desire  to  copulate  with  sexually  im- 
mature individuals.  The  normal  sexual  impulse  desires  what  is 
mature.  Violation  of  children  must  appear  atrocious  to  even 
the  coarsest  individual.  Still  the  sexual  attraction  that  a  young 
woman  or  a  young  man  who  is  not  matured  may  possess  for 
certain  men  or  women  may  be  comprehensible.  At  times  the 
stage  of  maturation  has  taken  place  before  the  legal  age  for 
sexual  consent  has  been  attained.  Instances  of  seduction  under 
such  circumstances  do  not  concern  us  here,  as  they  present  noth- 
ing pathological.  It  is  entirely  otherwise,  however,  when  puberty 
has  not  yet  set  in,  or  particularly  when  it  is  still  far  dis- 
tant. Coitus  with  such  young  persons  may  often  be  explained 
by  the  quantitative  anomaly  hypererosia,  particularly  in  the 
absence  of  any  other  outlet  for  the  excessive  desire,  or  by  the 


336    THE  UNSOUND  MIND  AND  THE  LAW 

existence  of  dementia  of  various  kinds.  As  a  typical  manifesta- 
tion, however,  we  meet  with  this  pronounced  tendency  to  violate 
immature  girls  more  especially  among  the  inhabitants  of  large 
cities  and  in  members  of  circles  surfeited  by  luxurious  modes  of 
life.  The  fact  that  in  the  majority  of  these  instances  it  is  vice 
and  not  disease  that  obtains  does  not  relieve  us,  of  course,  from 
the  necessity  of  investigating  the  circumstances  that  attend  each 
individual  case,  especially  as  the  relationship  between  crime  and 
insanity  is  a  close  one,  and  because  a  dissolute  mode  of  life  may 
be  but  the  stepping  stone  to  brain  disease. 

Let  us  now  consider  the  anomalies  in  the  order  given : 

(1)  Coitus  Associated  with  Non-Essential  Acts  appearing 
subjectively  as  essential  lust-producing  factors. 

Here  it  is  a  question  of  more  or  less  commonplace  or  eccentric 
and  often  disgusting  acts  that  are  preparatory  to  or  accompani- 
ments of  coitus,  and  which  serve  to  increase  the  individual  sexual 
enjoyment  or  even  to  render  the  coitus  itself  possible.  These 
acts  need  not  bear  a  direct  sexual  impress,  but  may,  objectively 
viewed,  appear  to  be  entirely  indifferent,  in  such  instances  the 
excitation  of  the  sexual  desire  is  aroused  through  transmission 
by  one  of  the  organs  of  special  sense.  Thus  Eulenburg,  among 
other  relevant  instances,  reports  one  in  which  the  man  was  able 
to  have  connection  only  after  the  woman  had  painted  her  abdo- 
men blue.  Such  manifestations,  in  the  absence  of  any  patho- 
logical factor,  may  be  harmless  diversions;  on  the  other  hand, 
in  connection  with  other  symptoms,  they  may  be  indications  of 
mental  disorder,  particularly  so  the  more  necessary  they  indi- 
vidually are  for  the  performance  of  the  act  of  coition  and  the 
more  disgusting  their  character. 

The  causation  of  mild  pain  by  tickling  and  beating  belongs 
to  such  acts.  While  this  in  itself  is  not  pathological,  for  it  is  a 
physiological  fact  that  lust  is  increased  by  tickling  and  beating, 
all  such  occurrences  should  arouse  a  suspicion  of  a  certain  en- 
feeblement  of  potency.  When  actual  torture  is  inflicted,  how- 
ever— and  to  this  we  shall  refer  again — a  pathological  state  prob- 
ably exists. 

(2)  Coitus-Like  Acts.  A  further  step  upon  the  field  of  hetero- 
sexual anomalies  takes  us  to  the  point  where  the  anus,  the 
axilla,  the  intermammary  space  and  the  mouth  are  substituted 
for  the  vagina.    The  desire  for  such  "displacement"  originates 


THE  ANOMALIES  OF  SEXUAL  SENSE     337 

partly  with  man,  partly  with  the  woman  herself.  It  may  often 
be  due  to  the  desire  to  prevent  conception,  to  an  abnormal 
anatomical  conformation  of  the  woman,  or  even  to  a  fear  of 
contagion,  in  all  of  which  instances,  of  course,  pathological  con- 
sideration cannot  obtain.  Often  also  it  is  the  consequence  of 
oversatiation  in  the  normal  sexual  field.  The  same  circum- 
stances that  have  led  to  the  oversatiation  may  constitute  a  factor 
for  the  causation  of  mental  disorders.  Hence,  notwithstanding 
the  existence  of  a  previous  history  that  would  indicate  vice,  dis- 
ease may  be  present.  Just  as  there  are  psychic  epidemics,  so  an 
entire  people  or,  what  is  more  frequent,  an  entire  social  class, 
may  become  infected  by  a  vice  implanted  upon  a  soil  that  has 
been  prepared  by  noisome  conditions;  then  an  unnatural 
abandonment  similar  to  that  which  the  individual  discovers  for 
himself  as  the  result  of  sexual  surfeit  makes  its  appearance  in 
so  and  so  many  others  in  consequence  of  the  imitative  impulse. 
Neuropathic  degeneration  may  often  constitute  a  factor  in  the 
dissemination  of  such  "functional"  vice.  Of  course,  where  the 
sexual  impulse  shows  such  anomalous  tendency  without  being 
satisfactorily  explained  by  oversatiation  or  social  infection, 
particularly  where  it  is  characterized  from  its  inception  by  a 
repugnance  to  coitus,  we  are  warranted  in  assuming  more  than 
a  neuropathic  taint,  and  upon  careful  investigation  we  will  be 
able  to  discover  other  symptoms  which  speak  for  the  existence  of 
actual  disease. 

Analogous  significance  is  to  be  attached  to  other  unnatural  acts 
known  as  ' '  succare, "  "  f ellare ' '  and  ' '  cunnilinetus. ' ' 

(3)  Sexual  Symbolism.  Closely  allied  to  the  anomalies  thus 
far  mentioned  is  that  other  class  in  which  the  actual  object  of 
sensual  attraction  appears  to  be  something  other  than  is  the  case 
in  normal  sexual  desire.  These  cases  have  been  designated  as 
sexual  symbolism.  In  them  a  certain  representation  or  substi- 
tution of  the  normal  object,  traceable  to  sexual  association  of 
ideas,  takes  place.  It  is  not  the  totality  of  the  individual,  not 
even  the  totality  of  his  body,  that  constitutes  the  attraction. 
The  "lover"  confines  his  "love"  to  a  part  of  the  person,  to  a 
part  of  the  body  or  to  a  psychic  quality,  or  he  concentrates  it 
upon  things  that  belong  to  but  are  not  part  of  the  person.  The 
less  the  actual  object  of  attraction  partakes  of  the  normal  or, 
from  an  objective  point  of  view,  the  more  repulsive  is  the,  sub- 


338    THE  UNSOUND  MIND  AND  THE  LAW 

stitute,  the  more  pronounced  must  the  anomaly  be  considered. 
Usually  it  will  be  found  to  be  based  upon  a  certain  impotence 
combined  with  psycho-sexual  degenerative  disorders. 

(a)  Sexual  fetishism.  In  accordance  with  the  suggestion  of 
Binet  and  of  Lombroso,  the  first  of  the  subdivisions  of  symbolism 
is  called  "fetishism."  This  name  is  derived  from  that  form  of 
religious  worship  in  which  the  deity  itself  becomes  subordinate 
to  tangible  derivative  objects,  as,  for  instance,  relics.  An  an- 
alogous substitution  of  a  part  for  the  whole  is  found  in  the  sexual 
domain,  as  when  a  certain  part  of  the  body,  such  as  the  hand  or 
the  foot,  constitutes  the  more  or  less  exclusive  attraction  for  the 
"lover." 

(1)  That  certain  parts  of  the  body  should  excite  special  inter- 
est is  in  itself  nothing  abnormal,  and  within  physiological  limits 
is  not  of  infrequent  occurrence.  It  is  abnormal,  however,  when 
a  single  part  absorbs  the  interest  to  such  an  extent  that  nothing 
but  indifference  is  felt  for  what  is  left,  particularly  when  the 
part  in  question  is  not  material  for  the  copulative  act  itself.  The 
anomaly  may  manifest  itself,  for  instance,  in  being  attracted  by 
nothing  but  a  foot  that  is  dirty,  or  by  a  part  of  the  body  that  is 
markedly  deformed.  The  practical  criminal  significance  of  this 
anomaly  is  evident.  Every  now  and  then  the  judicial  procedure 
conducted  against  the  man  who  cuts  braids  of  hair  from  the  heads 
of  women  brings  it  directly  into  public  view. 

(2)  "While  the  individual  value  the  lover  may  attach  to  a  cer- 
tain kind  of  dress  or  to  certain  articles  of  apparel  worn  by  the 
object  of  his  love  can  to  a  certain  extent  be  physiologically  ex- 
plained, we  must  assume  the  existence  of  a  pathological  state 
when  the  interest  in  the  woman  herself  becomes  subordinate  to 
the  interest  in  her  apparel.  Here  also  we  meet  with  variations 
in  degree,  the  most  pronounced  of  which  probably  is  that  in 
which  a  piece  of  wearing  apparel  represents  the  sole  means  for 
satisfying  the  sexual  desire. 

(3)  Still  another  grade  of  fetishism  is  present  when  certain 
materials,  as  such,  serve  as  independent  stimuli  of  the  sexual 
desire — that  is,  materials  that  have  not  been  made  up  into 
clothes  nor  are  subjectively  thought  of  in  their  relation  to  cloth- 
ing.    This  statement  refers  particularly  to  silk,  velvet  and  fur. 

According  to  Krafft-Ebing,  wheresoever  pathological  fetishism 
has  thus  far  been  observed  it  has  been  found  to  be  based  entirely 


THE  ANOMALIES  OF  SEXUAL  SENSE     339 

upon  a  psychopathic  constitution  or  to  have  occurred  in  con- 
junction with  actual  psychic  disease.  This  writer  also  believes 
fetishism  always  to  be  an  acquired  state,  or,  as  Binet  had  previ- 
ously pointed  out,  always  to  be  explained  by  the  occurrence  of 
some  special  determinative  cause  in  the  life  of  the  fetishist. 

Fetishism  in  woman  is  said  by  Krafft-Ebing  and  others  not  to 
exist.  It  may  well  be  that  sexual  love  in  women  less  often  leads 
to  flagrant  excesses  than  it  does  in  men,  and  for  this  reason  less 
often  is  the  cause  of  legal  investigation,  but  that  fetishism  is 
occasionally  encountered  in  a  very  marked  form  in  women  has 
been  shown  by  Moll.  Erotic  kleptomania,  a  form  of  erotic  fetish- 
ism in  which  the  fetish  that  is  to  satisfy  the  sexual  desire  must 
be  obtained  at  all  hazard,  even  by  theft,  is  encountered  only  in 
women.  Such  women  are  often  in  good  circumstances,  and  never 
attempt  to  convert  the  stolen  things  into  money. 

(b)  Lasciviencies.  Still  another  group  of  symbolism  is  con- 
stituted by  those  anomalies  represented  essentially  by  certain 
lasciviencies — that  is,  acts  of  a  voluptuous  nature  which,  however, 
do  not  go  so  far  that  they  may  be  looked  upon  as  physiologic 
substitutes  for  coitus,  as  is,  for  instance,  masturbation. 

Coitus  has  been  classed  among  the  anticipatory  pleasures.  As 
a  matter  of  fact  the  act  itself  is  preceded  by  a  stage  of  psychic 
ecstasy  from  which  certain  natures  derive  quite  as  intense  grati- 
fication as  from  the  copulation  itself. 

This  anticipatory  character  of  coitus  manifests  itself,  how- 
ever, in  still  other  ways.  The  mere  notion  of  coitus  may  be  ac- 
companied by  a  feeling  of  lust,  which  is  still  more  increased  by 
the  cooperation  of  the  organs  of  special  sense,  as  for  instance  by 
the  sight  of  obscene  pictures  or  sensual  acts.  Not  only  impres- 
sions of  sight  and  touch,  but  also  the  other  sense  stimuli,  par- 
ticularly those  of  taste  and  smell,  act  as  cooperative  factors  in 
this  regard.  This  is  a  physiological  fact  upon  which  a  number 
of  sexual  excesses  depend.  We  have  now  in  mind  those  acts 
which  of  themselves  do  not  constitute  a  physiological  satisfaction 
of  sexual  desire,  and  refer  particularly  to  the  pleasure  that  is 
taken  by  many  persons  in  looking  at  obscene  pictures,  in  sensu- 
ous manipulations,  in  listening  to  sensual  conversations,  in  sen- 
sual literature,  etc.  In  all  of  these  instances  it  is  not  only  the 
sensory  titillation  that  these  perceptions  arouse  in  the  individual 
imself  that  produces  pleasure,  but  a  peculiar  satisfaction  is  also 


340    THE  UNSOUND  MIND  AND  THE  LAW 

derived  from  having  brought  about  such  perceptions  in  other 
persons.  Such  pleasures  are  often  obtained  through  indiscre- 
tions of  all  kinds.  This  is  true  even  of  the  visual  offenses  com- 
mitted by  the  "voyeurs"  or  "peepers,"  for  which  the  Apocry- 
phal instance  of  ' '  Susanna  in  the  bath ' '  may  serve  as  a  typical 
example.  Of  special  practical  importance,  however,  are  those  acts 
by  which  other  persons,  with  or  without  their  consent,  are  sub- 
jected to  lascivious  intimacies  and  to  the  perception  of  sensual 
exhibitions.  Such  acts,  as  offenses  against  public  decency,  not 
infrequently  constitute  causes  for  criminal  procedure.  The  ones 
most  frequently  encountered — aside  from  forcible  osculation — 
are  touching  the  breasts  of  a  woman,  tapping  certain  parts  of 
her  body,  and  whispering  obscenities  into  her  ear. 

In  estimating  the  nature  of  such  manifestations  we  must  de- 
termine whether  they  are  merely  individual  occurrences,  whether 
they  constitute  an  essential  part  of  the  person's  sexual  life,  and 
whether  they  have  taken  place  in  a  potent  or  an  impotent  indi- 
vidual. Occurring  during  complete  potency,  as  an  occasional  ex- 
pression of  exuberance  or  lasciviousness,  particularly  under  the 
influence  of  alcohol,  they  have  no  special  significance;  nor  are 
they  deserving  of  particular  consideration  during  the  stage  of 
developing  or  of  declining  sexual  powers. 

But  when  pronounced  infractions  against  decency  are  com- 
mitted by  previously  well-behaved  individuals,  or  when  a  clear 
inherent  tendency  in  contradistinction  to  an  occasional  excess  is 
present,  the  existence  of  disease  may  be  assumed.  Then,  how- 
ever, other  symptoms  will  be  found  that  would  indicate  the  pres- 
ence, for  instance,  of  senile  dementia  or  a  paresis. 

There  still  remain  those  instances  in  which  the  sexual  desires 
of  an  individual  who  still  is  within  the  normal  period  of  sexual 
potency  manifest  themselves  mainly  in  the  direction  of  lascivi- 
encies,  although  ample  opportunities  for  coitus  exist.  The  cause 
for  this  state  may  be  either  a  physical  impotence  or  a  certain 
psychic  impotence  that  has  been  produced  by  a  surfeit  of  the 
normal  sexual  pleasures.  If  none  of  these  assumptions  is  upheld 
by  the  facts,  a  psychic  anomaly  must  exist  which  will  be  the 
more  severe  the  more  pronounced  is  the  aversion  to  coitus.  That 
such  an  anomaly  is  pathological  can  hardly  be  doubted.  The 
following  main  types  may  be  differentiated: 

(1)  The  "frotteurs,"  whose  sexual  impulse  manifests  itself 


THE  ANOMALIES  OF  SEXUAL  SENSE     341 

essentially  in  rubbing  themselves  against  women  in  crowded 
streets,  in  the  cars,  etc.  An  analogous  tendency  is  that  which 
expresses  itself  in  touching,  tapping  or  striking  certain  parts  of 
the  female  body. 

(2)  The  "exhibitionists"  who  in  the  presence  of  women  or  men 
ostentatiously  display  «that  part  of  the  body  which  decency 
otherwise  requires  to  be  covered,  their  purpose  being  to  arouse 
sexual  excitement  in  themselves  or  in  the  onlookers.  The  man- 
ner in  which  this  is  done  is  almost  always  the  same.  Some  go 
out  upon  the  streets  wearing  a  costume  specially  arranged  for 
the  purpose,  the  genitals  being  covered  by  an  overcoat  or  wrap 
which  at  the  opportune  moment  is  opened  or  drawn  aside. 

(3)  The  "verbal  exhibitionists,"  who  satisfy  their  lust  by 
whispering  obscene  remarks  into  the  ears  of  passersby. 

(4)  The  "ideal  exhibitionists,"  who  have  a  passion  for  show- 
ing lewd  pictures  or  writings. 

(5)  The  "voyeurs"  or  "peepers,"  who  satisfy  their  sexual 
desires  by  the  contemplation  of  naked  women. 

Eelated  to  individuals  of  this  category,  probably,  are  those 
who  content  themselves  with  staring  at  fully  clothed  women  and 
imagining  them  to  be  naked.  This  procedure  has  been  called 
illusionary  cohabitation. 

Actual  exhibitionism,  which  is  the  form  that  most  often  takes 
up  the  attention  of  the  courts,  when  it  is  a  pathological  mani- 
festation is  dependent  upon  intellectual  or  moral  feeble-minded- 
ness,  or  at  least  upon  a  temporary  blocking  of  intellectual  and 
ethical  functions,  associated  with  an  augmented  desire  and  often 
accompanied  by  a  disordered  state  of  consciousness.  Frequently 
it  is  associated  with  an  oppressive  state  of  fear  which  finds  an 
outlet  in  the  exhibitionistic  act.  Epileptics  constitute  a  rela- 
tively large  contingent  of  such  performers,  and  the  twilight 
states  seem  to  be  the  period  in  which  it  most  often  occurs.  Ex- 
hibitionism is  also  frequent  in  senile  dements,  paretics,  the  feeble- 
minded and  alcoholics.  It  is  often  met  with  in  inveterate  as 
well  as  in  occasional  masturbators,  in  neurasthenics  with  trans- 
itory psychic  disorder  and  in  neuropaths  of  other  kinds.  The 
exhibitionists  in  whom  the  determination  of  legal  responsibility 
causes  the  greatest  difficulty  are  the  habitual  exhibitionists  who 
know  precisely  what  they  want.  They  represent  the  largest  con- 
tingent of  those  whom  we  encounter,  and  occupy  the  borderline 


342    THE  UNSOUND  MIND  AND  THE  LAW 

between  health  and  disease,  now  leaning  somewhat  toward  health, 
now  somewhat  toward  disease. 

Forensically  every  exhibitionist  should  be  subjected  to  a  psy- 
chiatric examination,  for  the  act  in  itself  must  always  create  a 
suspicion  of  some  existing  mental  disorder.  In  women,  exhibi- 
tionism is  of  infrequent  occurrence. 

The  tendency  to  lascivities  appears  with  special  emphasis  in 
the  manifestation  known  as  Pygmalionism  and  its  subdivisions, 
a  group  of  anomalies  which  is  directly  allied  to  the  class  of 
"voyeurs"  and  "illusionary  cohabiters, "  of  which  we  have  just 
spoken.  The  basal  form  is  represented  by  a  passionate  affection 
for  statues  as  typified  by  the  Greek  sculptor  and  King  of  Cyprus, 
Pygmalion.  This  passion  has  repeatedly  in  ancient  and  modern 
times  led  to  a  violation  of  marble,  bronze  or  wooden  images. 

A  derivative  of  this  form  is  instanced  by  the  custom  of  super- 
annuated libertines  in  having  naked  women  pose  as  statues,  then 
arousing  them  to  life  in  order,  if  possible,  to  subject  them  to 
sexual  intercourse.  Still  another  grade  is  that  of  necrophilia,  the 
carnal  passion  for  dead  bodies  and  the  violation  of  corpses. 

Finally,  as  constituting  still  another  form  of  symbolism,  we 
must  refer  to  that  group  in  which  the  excrements  from  the 
female  body  constitute  the  object  of  sexual  attraction. 

(4)  Algolagnia.  The  parerosias  to  which  we  have  thus  far 
given  our  attention  have  been  characterized  by  an  aberrent  di- 
rection of  the  sexual  desire. 

A  different  category  of  anomalies,  which  Eulenburg  was  the 
first  to  collate  and  to  designate  as  "algolagnia,"  is  made  up  of 
those  in  which  the  sensual  experience  is  markedly  modified  by 
the  feeling  of  humiliation,  degradation,  violence  or  cruelty  that 
accompanies  it.  This  subjection,  degradation,  etc.,  may  exist  in 
two  different  ways,  being  either  a  material  factor  in  the  mind 
of  the  person  who  enforces  it,  or  in  that  of  the  person  who  ex- 
periences it.  In  the  former  instance  we  speak  in  general  of 
Sadism,  in  the  latter  of  Masochism.  Let  us  now  turn  to  the 
first  group  and  give  our  attention  to  Sadism  in  the  male. 

(a)  Sadism,  or  lagnanomania  on  the  part  of  the  man.  In 
the  copulative  act,  the  man  appears  to  exercise  the  aggressive, 
and  the  woman  the  receptive  part.  In  the  psychic  domain  of 
love  there  exists  an  analogous  condition,  in  that  it  is  usually  the 
woman  who  subordinates  herself,  while  the  man  strives  through 


THE  ANOMALIES  OF  SEXUAL  SENSE    343 

possession,  to  gain  a  certain  dominion  over  the  woman.  When 
this  spirit  of  domination  constitutes  an  essential  factor,  or  when 
it  preponderates  so  that  every  other  feeling  is  forced  into  the 
background,  it  becomes  an  anomaly.  Moreover,  it  is  a  fact  that 
without  transgression  of  the  physiological  limits,  both  man  and 
woman  during  the  supreme  ecstasy  of  coitus  may  commit  acts 
such  as  biting  and  scratching  which  are  not  far  from  brutal. 
This  becomes  an  anomaly  when  such  acts  are  manifestations  of  a 
permanent  state  of  mind,  when  they  are  vital  for  the  production 
of  sensual  pleasure,  when  the  tendency  to  commit  them  is  so 
great  that  it  overtops  or  precludes  all  other  feelings  and  particu- 
larly when  these  acts  bear  the  impress  of  actual  cruelty.  On  the 
other  hand,  it  is  also  a  fact  that  cruel  acts,  in  their  turn,  are 
capable  of  producing  notions  of  sensual  pleasure. 

The  exaggerated  sense  of  dominance  expresses  itself  by  the 
dispensation  of  humiliation  and  chastisement;  exaggerated  hu- 
miliation leads  to  degradation,  exaggerated  chastisement  to  cruel- 
ty and  brutality. 

Dominance,  in  its  most  extreme  manifestation,  is  represented 
by  destruction  of  the  dependents.  Thereupon  destruction  also 
constitutes  the  greatest  satisfaction  that  the  feeling  of  dominance 
is  able  to  give — a  satisfaction  that,  however,  thwarts  itself  as  it 
brings  about  the  permanent  loss  of  the  subservient  subject.  Ex- 
cessive cruelty  caused  by  excessive  sensuality,  when  carried  to 
its  extreme  limits,  may,  of  course,  lead  to  a  similar  result. 

Wheresoever  in  the  domain  of  sexual  life  we  encounter  such 
excrescences  as  actual  happenings,  it  is  fair  to  assume  the  ex- 
istence of  mental  disease ;  but  never  should  such  acts  in  them- 
selves serve  as  proof  of  disease,  for  there  is  no  form  of  horror  or 
brutality  so  repugnant  that  it  may  not  occasionally  be  committed 
by  a  person  who  is  in  mental  health. 

As  a  psychopathological  manifestation  Sadism  (so-called  after 
the  Marquis  of  Sade,  whose  life  and  writings  picture  the  condi- 
tion) is  dependent  preeminently,  at  any  rate  in  its  most  pro- 
nounced form,  upon  congenital  or  acquired  feeble-mindedness, 
upon  alcoholism,  hysteria,  epileptic  psychoses  or  senile  dementia. 
Moreover,  it  occurs  not  only  as  a  chronic  state,  but  also  episodi- 
cally. 

In  estimating  the  severity  of  each  individual  pathological  case, 
we  should  remember  that  the  objective  state  of  affairs  should 


344    THE  UNSOUND  MIND  AND  THE  LAW 

never  be  taken  as  a  measure  for  the  degree  of  existing  disease. 
This  is  important,  because  without  reflection  we  would  be  in- 
clined to  attribute  instances  of  slight  maltreatment  to  a  mild  de- 
gree of  mental  disturbance,  and  vice-versa.  At  the  same  time 
it  cannot  be  denied  that  such  relationship  often  does  actually 
exist.  The  diversity  and  grades  of  these  cases  are  unlimited, 
and  each  one  must  be  appraised  in  accordance  with  all  the  at- 
tendant circumstances.  Let  us  now  attempt  to  give  a  sketch  of 
the  main  types : 

First  to  be  considered  are  the  acts  of  simple  humiliation.  The 
woman,  for  instance,  is  forced  to  kneel  before  the  man,  to  kiss 
his  foot,  etc.  Insistence  upon  humiliation  in  public  is  not  ex- 
ceptional. Or  the  woman  is  subjected  to  degrading  indecencies, 
such  as  urinating  upon  her  body,  etc.  Occupying  a  position  be- 
tween humiliation  and  maltreatment  are  those  instances  in  which 
ink,  acid,  feces,  urine,  etc.,  are  thrown  upon  strange  women  in  the 
public  streets. 

It  is  in  the  field  of  maltreatment  that  we  first  encounter  what 
is  known  as  active  flagellation,  either  preceding  the  act  of  copula- 
tion or  supplanting  it  entirely.  In  such  cases  we  usually  find 
partial  or  total  impotence  as  a  factor.  It  is  here  also  that  we 
meet  with  scratching  or  biting  of  the  woman's  body,  with  or 
without  coitus.  Of  eminent  forensic  significance  is  the  stick- 
ing of  needles  into  one 's  own  body  until  the  blood  is  drawn.  A 
typical  example  of  this  practice  is  found  in  the  Marquis  of  Sade. 

Actual  laceration  of  the  body  may  be  the  result  of  such  pro- 
cedure. The  culmination  of  barbarity  is  represented  by  what  is 
known  as  lust-murder,  in  which  the  killing  may  precede  or  fol- 
low the  coitus,  or  it  may  take  place  without  any  copulation,  being 
of  itself  the  means  of  satisfying  the  sensual  desire.  Such  murder 
occasionally  takes  the  form  of  the  most  horrible  mutilations  and 
dismemberment  of  the  woman's  body.  Sometimes  parts  of  the 
corpse,  the  specifically  sexual  ones,  are  set  aside  to  be  used 
later  for  sensual  satisfaction.  This  last  mentioned  factor  now 
and  then  constitutes  the  main  and  exclusive  purpose  of  the  mur- 
der, from  the  very  beginning.  In  some  cases  the  murder  may  be 
purely  symbolic.  When  this  happens,  no  attempt  may  be  made 
to  outrage  the  integrity  of  the  living  woman,  and  all  barbarity 
may  be  lacking  except  as  it  exists  in  the  imagination  of  the  ag- 
gressor.   Then,  too,  the  individual  may  content  himself  with  any 


THE  ANOMALIES  OF  SEXUAL  SENSE    345 

existing  female  corpse,  which  is  violated,  dismembered  and  per- 
haps anthropophagously  employed. 

Symbolism  is  also  the  explanation  for  the  substitution  of  the 
bodies  or  other  individuals  or  animals  for  that  of  woman.  This 
statement,  of  course,  applies  as  well  to  the  baser  forms  of  vio- 
lence and  cruelty,  above  all  to  flagellation. 

(b)  Sadism  on  the  part  of  the  woman.  In  what  has  preceded 
we  have  considered  Sadism  in  man.  So  far  as  Sadism  in  woman 
is  concerned,  there  exist  up  to  the  present  time  but  few  actual 
observations.  In  romantic  literature  and  in  history,  however, 
many  instances  are  to  be  found  which  can  be  understood  only 
in  the  light  of  female  Sadism. 

As  compared  with  male  Sadism,  the  female  form  presents  no 
peculiarities  even  if  our  consideration  be  confined  to  the  barbar- 
ous practices  that  are  dependent  upon  sensual  pleasures.  It  is 
different,  however,  when  we  consider  those  acts  that  bear  not  so 
much  a  sensual,  barbarous  impress  as  a  specific  humiliating,  sub- 
missive or  subservient  character.  When  committed  by  the  man 
these  acts  are  the  outgrowth  of  the  normal  desire  to  have  posses- 
sion of  the  woman;  on  the  part  of  the  woman,  however,  they 
imply  an  anomalous  inversion  of  the  normal  instinct  of  sub- 
jection to  the  man,  and  hence  no  longer  belong  to  the  domain 
of  actual  heterosexual  anomalies. 

(c)  Masochism  or  machlachomania.  The  opposite  of  Sadism 
is  Masochism,  an  anomaly  in  which  humiliations,  acts  of  violence 
and  maltreatment  are  endured  with  a  feeling  of  sensual  pleasure. 

We  have  already  referred  to  the  fact  that  mild  pain  may  act 
physiologically  as  a  sexual  excitant.  It  is  anomalous,  however, 
when  the  blows  or  even  actual  maltreatment  are  endured  because 
they  constitute  the  essential  or  dominating  factor  in  the  percep- 
tion of  sensual  enjoyment.  We  have  also  stated  that  love  in 
woman  is  normally  characterized  by  a  certain  subordination  to 
man,  just  as  in  the  sexual  act  the  woman  bears  the  passive  part 
while  to  man  is  apportioned,  physically  as  well  as  psychically, 
the  more  active  role. 

This,  however,  by  no  means  precludes  the  occurrence  of  epochs 
in  the  normal  life  of  man  in  which  he  may  find  his  happiness  in 
submitting  and  subjecting  himself  to  an  adoration  on  the  part 
of  the  woman.  The  occurrence  of  such  passing  fancies  and  ex- 
travagancies is,  however,  of  no  moment  in  a  consideration  of  the 


346    THE  UNSOUND  MIND  AND  THE  LAW 

fundamental  traits  of  man 's  love.  Hence  when  a  man  possesses 
an  inherent  tendency  to  subjection  we  must  consider  this  quality 
as  one  that  is  qualitatively  foreign  to  normal  male  love,  for  he 
then  appears  in  a  role  that  belongs  to  woman  and  we  are  dealing 
with  an  inversion. 

This  same  mental  tendency  to  subjection  becomes  an  anomaly 
only  when  it  is  exaggerated  and  therefore  merits  consideration 
solely  as  a  quantitative  anomaly ;  it  becomes  a  qualitative  anom- 
aly only  when  the  tendency  to  subjection  loses  its  secondary 
significance,  when  the  subjection  becomes  a  main  factor  in  the 
woman's  existence.  It  is  such  anomalies  that  constitute  the  chief 
subject  in  the  work  of  the  Austrian  novelist,  Sacher-Masoch 
(1836  to  1895)  after  whom  the  scientific  designation  "Masoch- 
ism" has  been  formed. 

(1)  Masochism  upon  the  Part  of  the  Man.  Masochism  as  a 
manifestation  of  disease  has  been  found  to  exist  in  man  essen- 
tially upon  the  same  pathological  basis  as  Sadism. 

What  the  Sadist  tends  to  inflict  is  in  the  main  what  the  Ma- 
sochist  sensually  desires  to  suffer,  except  that  the  severe  forms 
of  aggression  against  his  physical  integrity  are  pictures  of  his 
fantasy  and  are  not  longed  for  in  the  shape  of  actual  realities. 
Naturally  Masochism  occurs  in  different  forms  and  intensity  in 
different  individuals.  In  so  far,  however,  as  the  Masochistic 
percepts  or  Masochistic  acts  in  their  entirety  are  concerned,  it 
may  well  be  said  that  the  most  vivid  imagination  cannot  con- 
struct anything  in  the  line  of  humiliation,  degradation,  maltreat- 
ment, etc.,  that  has  not  imaginarily  or  actually  formed  part  of 
the  lustful  experience  of  one  Masochist  or  another.  As  in  Sad- 
ism, so  in  Masochism  there  exists  a  symbolism.  In  this  regard  let 
us  bear  in  mind  especially  the  close  relationship  that  exists  be- 
tween forms  of  Masochism  and  fetishism.  In  fetishism  it  is,  for 
example,  the  foot  or  the  shoe  of  women  that  constitutes  the  spe- 
cial part  which  is  the  center  of  interest ;  in  Masochism  this  part 
assumes  its  importance  as  a  means  of  humiliation,  as  a  means 
of  maltreatment.  Thus  it  may  happen  that  an  individual  will 
"love"  the  foot  in  particular,  not  according  to  the  fetishistic 
principle  of  the  part  for  the  whole,  but  rather  as  the  visible  at- 
tribute of  the  master's  power.  In  conformity  with  the  nature 
of  Masochism  the  foot  kiss  will  afford  the  Masochist  abundant 
sensual  pleasure  as  compared  with  the  fetishist,  for  naturally  the 


THE  ANOMALIES  OP  SEXUAL  SENSE     347 

humiliation  will  be  greater  when  the  castigation  is  not  merely 
accepted  than  where  the  one  who  inflicts  the  castigation  is  also 
looked  upon  with  a  feeling  of  reverence  and  thankfulness. 

(2)  Masochism  upon  the  part  of  the  Woman.  Actual  experi- 
ences with  Masochism  in  woman  seem  to  be  very  infrequent. 
But  wheresoever  it  has  been  encountered  it  does  not  seem  to 
differ  from  that  which  has  been  noted  in  man. 

In  concluding  this  chapter,  a  statement  that  applies  to  Sadism 
as  well  as  to  Masochism  may  not  be  out  of  place,  viz.,  that  the 
individuals  thus  affected  frequently  ascribe  the  commencement 
of  their  anomaly  to  certain  accidental  occurrences  in  the  early 
years  of  their  life.  Such  statements  should  always  be  received 
with  a  full  understanding  that  the  actual  cause  of  an  anomaly 
should  not  be  confounded  with  the  incident  that  first  gives  rise 
to  its  manifestation.  No  doubt  the  anomalies  now  under  con- 
sideration, as  well  as  all  others,  may  be  the  direct  result  of  cer- 
tain factors,  but  in  the  majority  of  instances  a  disposition  to 
their  development  based  upon  an  inherited  psychopathic  taint 
will  be  found  to  exist. 

Although  all  typical  Sadists  and  Masochists  have  many  psy- 
chic traits  in  common,  it  will  be  found  that  the  Sadists  as  a  rule 
are  energetic,  unscrupulous  and  barbarous  in  all  their  tendencies 
and  actions,  while  the  Masochists  will  be  found  to  be  undecided, 
weak  and  servile,  but  withal  treacherous  and  revengeful.  Never- 
theless, Masochism  and  Sadism,  notwithstanding  their  partial 
antithesis,  may  exist  together  in  one  and  the  same  individual, 
just  as  any  combination  of  the  heterosexual  anomalies  thus  far 
considered  may  be  present  without  any  sharp  line  of  demarcation. 

Forensically  the  Sadist  is  more  often  brought  to  the  tribunal 
of  justice  than  the  Masochist.  It  is  manifest  that  the  violation 
of  dead  bodies,  the  personal  injuries  and  personal  insults  that 
occur  in  Sadism  will  be  judicially  punished,  while  the  Masochist 
always  is  a  placid  sufferer. 

B.    HOMOSEXUAL  ANOMALIES 

Let  us  now  take  up  another  class  of  anomalies  which  is  char- 
acterized by  a  sexual  inclination  toward  one's  own  sex,  and 
which  has  been  designated  as  uranism,  homosexual  parerosia  or 
sexual  inversion.     Various  theories  have  been  propounded  to 


348    THE  UNSOUND  MIND  AND  THE  LAW 

explain  this  manifestation,  and  of  these  that  of  Krafft-Ebing 
seems  to  be  the  one  most  acceptable.  He  starts  from  the  fact  that 
three  component  parts  of  the  sexual  system  are  interconnected 
by  nerve  tracts  and  stand  in  a  functional  mutational  relationship 
to  one  another.    These  parts  are: 

(1)  The  sexual  glands  and  organs  of  fructification. 

(2)  The  spinal  sexual  centers,  having  inhibitory,  excitatory, 
nutritional  and  secretory  functions,  and 

(3)  The  cerebral  sexual  centers  as  somato-psychic  factors. 
He  argues  that  the  parts  first  mentioned  (sexual  glands  and 

organs  of  fructification)  are  at  first  bi-sexual  in  the  foetus,  and 
develop  their  monosexuality  only  in  the  third  month  of  foetal 
life;  and,  on  account  of  the  intimate  connection  and  the  muta- 
tional relationship  of  these  three  parts,  that  the  primarily  bi- 
sexual disposition  of  the  parts  first  mentioned  also  presupposes 
a  primary  bi-sexuality  in  the  other  domains  and  that  similarly 
the  monosexual  development  of  the  first  mentioned  part  necessi- 
tates a  monosexual  development  of  the  two  remaining  ones — 
hence,  also,  of  the  cerebral  part.  At  the  same  time  he  draws  the 
conclusion — which  he  has  found  corroborated  by  experience — 
that  normally  the  cerebral  center  and  the  corresponding  sexual 
gland  developed  together — that  is  to  say,  where  in  the  bi-sexual 
system  the  male  glands  develop  while  the  female  gland  atrophies, 
the  male  cerebral  center  will  also  develop  and  the  female  cere- 
bral center  will  atrophy.  "The  more  pronounced  this  differen- 
tiation the  more  anthropologically  perfect  is  the  individual. ' ' 

By  assuming  a  degenerative  disturbance  in  the  harmonious  de- 
velopment of  the  three  sexual  parts,  he  then  explains  the  homo- 
sexual desire,  and  considers  the  degree  of  that  disturbance  to  be 
determinative  for  the  severity  of  the  existing  perversion.  For 
instance,  when  in  the  case  of  a  male  gland  it  is  the  female  and 
not  the  male  cerebral  center  that  develops,  a  homosexual  ten- 
dency will  arise  which  will  be  the  more  pronounced,  and  the  more 
exclusive,  the  more  perfectly  this  female  brain  center  is  devel- 
oped. When,  however,  again  assuming  a  male  glandular  devel- 
opment, the  male  and  the  female  brain  centers  develop  con- 
jointly, a  mental  hermaphroditic  development  will  ensue.  The 
question  of  a  hermaphroditic  development  of  the  gland  itself 
does  not  concern  us  here,  for  in  such  case  the  psychic  manifesta- 
tions cannot  be  considered  primarily  anomalous. 


THE  ANOMALIES  OF  SEXUAL  SENSE    349 

Homosexual  desire,  therefore,  according  to  Krafft-Ebing,  is 
a  degenerative  manifestation,  and  clinically  a  degenerative  symp- 
tom. This  postulate,  he  holds,  applies  not  only  to  the  congenital 
but  also  to  the  acquired  forms  of  homosexual  desire.  In  so  far 
as  the  congenital  anomaly  is  concerned  we  cannot  but  endorse 
Krafft-Ebing 's  conclusions,  as  well  as  the  consequent  deduction 
in  regard  to  the  evaluation  of  the  disorders  that  develop  spon- 
taneously during  the  stage  of  sexual  development.  That  Krafft- 
Ebing 's  conception  should  apply  to  all  other  instances  of  this 
perversion  cannot  be  admitted,  however,  so  long  as  the  action 
of  other  productive  causes  has  not  been  excluded.  In  accord- 
ance with  his  conception,  Krafft-Ebing  very  justly  discounte- 
nances the  idea,  supported  by  Lombroso,  that  homosexual  desire 
represents  an  atavistic  reversion  to  animal  type. 

Let  us  now  ask  what  form  these  perversions  take.  The  reply 
to  this  question  cannot  be  based  upon  any  distinction  between 
congenital  and  acquired  homosexuality,  inasmuch  as  all  pos- 
sible manifestations  occur  in  both  forms,  although  the  last  men- 
tioned one  seems  to  show  a  preference  for  certain  acts.  Fre- 
quently the  desire  is  characterized  by  its  extraordinary  intensity, 
the  love  by  its  consuming  fervency.  Moreover,  the  combination 
of  homosexuality  with,  or  its  modification  by,  sexual  symbolism 
and  Masochism  is  so  frequent  as  to  be  almost  constant.  Its 
association  with  Sadism  is  much  less  frequent.  In  practice,  there- 
fore, we  encounter  homosexuality  in  every  possible  form,  and 
also  here  it  may  be  said  that  nothing  can  be  imagined  in  the 
personal  relations  of  two  individuals  of  the  same  sex  that  has  not 
actually  occurred. 

On  the  other  hand,  it  is  also  a  fact  that  in  a  comparatively 
large  number  of  homosexual  individuals  the  anomalous  tendency 
never  takes  the  form  of  an  overt  act.  Some  individuals  are  able 
so  to  control  themselves  that  such  acts  are  entirely  avoided,  or 
they  take  on  the  most  superficial  form,  a  sensual  pressure  of 
the  hand  sufficing  to  express  that  which  in  a  person  of  less  self- 
control  might  have  led  to  the  most  pronounced  excesses.  Whether 
a  person  is  able  at  a  given  time  to  control  himself  in  such  a 
manner  will  only  too  often  be  dependent  upon  circumstances 
that  are  to  a  large  extent  accidental,  namely  his  general  consti- 
tution, his  condition  of  life,  his  education  and  above  all  his 
early  training. 


350    THE  UNSOUND  MIND  AND  THE  LAW 

Even  under  the  best  conditions  the  moral  vulnerability  of  such 
an  individual  will  always  hang  upon  a  thread;  any  slight  dis- 
turbance of  mental  poise,  due  perhaps  to  a  glass  of  wine  too 
much  or  to  a  sudden  disappointment,  may  cause  his  downfall. 
Then,  as  a  rule,  the  fallacious  conclusion  will  be  drawn  that, 
having  been  strong  enough  all  his  life  to  master  himself,  he 
should  have  been  able  to  do  so  this  time. 

Deserving  of  special  consideration  in  this  connection  is  the 
inhibitory  power  exerted  by  that  broad  culture  that  enlarges 
a  person's  horizon  and  places  him  upon  a  higher  plane.  It  is 
this  factor  that  is  so  often  lacking  in  many  sexual  perverts  who 
are  particularly  talented  intellectually  or  artistically  and  thus 
naturally  occupy  unusual  positions  in  life. 

Let  us  now  turn  to  the  individual  kinds  of  homosexual  anoma- 
lies, taking  up  first  the  congenital  form  in  the  male. 

(1)  Congenital  Homosexual  Parerosia  in  the  Male.  The  mild- 
est form  of  manifestation  here  is  represented  by  what  has  been 
called  psychic  hermaphrodism,  in  which  there  exists  side  by  side 
a  sexual  desire  for  men.  In  such  instances  Krafft-Ebing  has 
said  that  the  desire  for  women  is  always  much  weaker  than  that 
for  men  and  is  present  but  episodically.  As  a  result  of  my 
experience,  I  know  that  the  reverse  conditions,  as  well  as  one 
in  which  the  desire  is  equally  proportioned,  are  not  infrequent. 
With  Krafft-Ebing 's  statement  that  under  certain  conditions 
such  hermaphrodisia  may  develop  in  complete  homosexuality  I 
am  in  full  accord. 

The  next  stage  is  characterized  by  complete  homosexual — 
that  is,  by  a  desire  exclusively  for  the  male  sex,  marked  indif- 
ference toward  the  female  sex  as  such,  and  an  aversion  or  revul- 
sion against  coitus  with  woman.  In  other  ways  the  mental 
habitus  and  the  entire  conformation  of  the  body  are  of  the  male 
type.  This  is  the  type  known  as  uranism  or  urningism.  Here 
the  homosexual  love  is  for  the  most  part  extravagant,  capable  of 
great  sacrifice,  and  by  no  means  exclusively  sensual.  In  his 
sexual  relation  the  urning  always  has  the  sensation  of  the  male, 
even  where  his  role  is  the  sexual  act  is  a  passive  one. 

Paedicatio  (pederasty*)  is  most  exceptional.  The  urning  is 
usually  also  a  neurasthenic.    Very  frequently  all  sorts  of  pare- 

*  The  term  "pederasty"  is  much  used  to  designate  actual  immissio  in  anum, 
whereas  in  ancient  Greece  it  was  applied  to  homosexual  love  in  general. 


THE  ANOMALIES  OF  SEXUAL  SENSE    351 

rosias  and  hyperosias  coexist,  and  thus  create  manifold  varia- 
tions in  the  nature  of  the  sexual  relations. 

The  less  typical  forms  of  urningism  are  more  like  the  next 
stage,  effeminatio.  Here  the  physical  conformation  is  male,  the 
psychic  habitus  female.  There  exists  a  disinclination  for  specifi- 
cally male  occupations,  distractions,  games  and  sports,  with  a 
tendency  toward  the  corresponding  female  things.  Female  taste 
in  dress  and  reading,  a  positive  disgust  for  sexual  intercourse 
and  exclusive  desire  for  the  passive  role  in  sexual  intercourse 
with  men  and  exclusively  female  sensations  in  all  sexual  acts  are 
among  its  traits.  Anal  coitus  is  not  of  frequent  occurrence. 
Copulation  with  sexually  immature  male  individuals,  according 
to  Krafft-Ebing,  has  never  been  noted.  When  the  female  mental 
attributes  are  associated  with  a  physical  conformation  that  ap- 
proximates the  female  type,  we  speak  of  androgyny.  There  are, 
however,  various  connecting  links  between  the  latter  and  effemi- 
natio. The  physical  anomaly  to  which  we  have  referred  impli- 
cates the  bony  structures,  and  adipose  tissue,  the  facial  conforma- 
tion, the  voice,  etc.,  while  the  sexual  organs  themselves  are  male 
throughout,  although  otherwise  often  degenerated  (epi-  and 
hypo-spadia) . 

(2)  Congenital  Homosexual  Parerosia  in  the  Female.  Con- 
genital homosexual  parerosia  in  woman  is  represented  by  four 
grades  that  are  analogous  to  those  encountered  in  the  male. 
They  are: 

(1)  Psychic  hermaphrodisia ;  (2)  female  urningism;  (3)  vir- 
aginity  (effeminatio  in  man)  ;  (4)  Gynandria  (androgynia  in 
man). 

These  gradations  are  of  course  not  so  sharply  differentiated 
by  their  sexual  acts  as  are  the  homosexual  relations  in  man,  in 
whom  the  body  conformation  admits  of  more  characteristic  dif- 
ferences. Above  all,  however,  the  instances  that  have  been  ac- 
tually observed  are  very  sparse.  The  less  aggressive  nature  of 
female  love,  the  peculiarity  of  most  statutes  in  ignoring  sexual 
offenses  between  woman  and  woman,  and  possibly  also  the  greater 
skill  in  dissimulation^  possessed  by  women,  as  well  as  the  persist- 
ence of  potency  even  when  there  exists  a  disgust  for  coitus,  may 
to  an  extent  explain  this  fact. 

So  far  as  concerns  the  terminology,  "Lesbic"  or  "Sapphic 
love"  should  be  noted  as  a  general  designation  of  sexual  inter- 


352     THE  UNSOUND  MIND  AND  THE  LAW 

course  between  female  and  female,  and  "tribadism"  as  descrip- 
tive of  manipulation  of  the  sexual  organs  of  the  opposite  sex. 

(3)  Acquired  Homosexual  Parerosia.    Homosexual  parerosia 
may  also  be  acquired.    This  is  possible  in  various  ways.    Even 
within  the  confines  of  homosexuality  we  know  that  the  originally 
lighter  form  may  under  certain  conditions  become  transformed 
into  the  more  serious  ones.     These  conditions  are  represented 
above  all  by  improper  training,  evil  associations,  misdirected 
reading,  and  an  enfeeblement  of  the  general  constitution,  but 
more  especially  of  the  entire  sexual  system  and  of  the  moral 
stamina  of  an  individual.     A  person  originally  mentally  and 
physically   healthy,    cultured    and    morally    well-trained,    may 
through  slight  provocations  gradually  become  the  contrary  of  his 
former  self.    He  commits  an  indiscretion,  forgets  himself  again 
and  again,  his  moral  sanctity  is  violated,  his  ethical  foundation 
becomes  more  and  more  unstable;  excesses  in  baccho  et  venere, 
regrets,  sorrow  and  anxiety,  over-exertion  in  order  to  retrieve 
what  has  been  lost  represent  the  early  stages;  indolent  acqui- 
escence to  his  passions  and  to  the  fortuitous  conditions  that  sur- 
round him  make  up  the  final  act  of  a  cataclysm.     Thus  there 
can  be  no  doubt  that  in  a  person  originally  healthy  and  men- 
tally sound,  acquired  moral  deficiencies  and  occasional  abnormal 
sexual  acts  may  gradually  lead  to  inherent  sexual  anomalies. 
All  the  more  possible  may  this  be,  therefore,  when  a  neuropathic 
basis  exists,  and  particularly  when  the  individual  belongs  to  a 
social  class  in  which  such  sexual  acts  are  so  customary  that  they 
serve  as  a  direct  means  of  psychic  infection.    Beyond  this,  how- 
ever, we  cannot  go,  for,  as  Krafft-Ebing  says,  no  male  individual 
who  is  free  from  hereditary  taint  will  under  any  circumstances 
become  a  sexual  pervert  and  find  pleasure  in  taking  over  the 
female  role.    Moreover,  he  characterizes  the  anomalous  desires  of 
those  persons  as  a  "sexual  degradation"  and  thus  would  seem 
to  consider  them  essentially  as  a  vice.     Correspondingly  this 
would  apply  also  to  woman.    To  me  it  seems  that  our  experience 
upon  this  field  is  still  not  sufficiently  large  to  warrant  a  conclu- 
sion so  sweeping. 

The  acquired  homosexual  parerosias  have  been  subdivided  into 
numerous  grades  according  to  the  dominance  of  the  desire  for 
the  same  sex.  It  is  this  attempt  to  classify  and  subdivide  that 
has  covered  the  entire  subject  with  confusion  and  misunder- 


THE  ANOMALIES  OF  SEXUAL  SENSE     353 

standing.  Ziehen  has  clarified  matters  by  the  following  simple 
and  comprehensible  classification:  He  divides  the  qualitative 
aberrations  of  sexual  impulse  into  four  classes:  the  constitu- 
tional, the  associative,  the  implanted  and  the  compensatory  ones. 
To  the  first  category  he  assigns  all  true  homosexual  perverts  with 
manifest  lasting  aversion  toward  the  opposite  sex  and  of  whom 
some  have  deviations  in  their  somatic  sexual  features;  to  the 
second  he  allots  all  those  in  whom  a  determining  memory  picture 
substitutes  abnormal  mental  associations  of  the  most  varied  kind 
for  the  emotional  impress  of  the  normal  sexual  act ;  to  the  third 
and  fourth  classes,  respectively,  are  assigned  those  individuals 
whose  perversion  has  been  brought  about  by  imitation,  deduc- 
tion or  suggestion,  and  those  who  become  perverts  on  account 
of  lack  of  normal  sexual  satisfaction. 

Psychopathological  significance  of  homosexual  parerosia. 
The  foregoing  classification  leads  directly  up  to  the  question 
whether  and  to  what  extent  the  different  types  of  homosexual 
parerosia  are  to  be  considered  pathological.  As  we  have  re- 
peatedly emphasized,  an  individual  act  as  such  can  never  be 
decisive ;  any  act  can  apriori  be  looked  upon  as  pathological  only 
in  so  far  as  it  is  the  proper  manifestation  of  a  corresponding 
psychic  tendency. 

An  outward  manifestation  that  in  one  instance  is  due  to  a 
pathological  state  may  in  another  be  dependent  upon  other 
causes.  Among  the  other  causes  that  have  a  practical  bearing 
in  this  regard  are  above  all  a  surfeit  of  normal  sexual  connec- 
tion, a  lack  of  opportunity  for  such  connection,  sexual  immo- 
rality or  social  infection.  The  last  may  embrace  entire  peoples, 
particularly  when,  as  is  the  case  in  some  of  them,  woman  occu- 
pies an  inferior  position  and  the  sexes  thus,  excepting  in  their 
marriage  relations,  are  socially  disunited.  Typical  of  such  con- 
dition are  ancient  Greece  and  the  Orient  of  the  past  and  of  the 
present.  "Where  we  speak  of  the  demands  of  an  actual  psychic 
desire,  we  of  course  mean  more  than  simple  liking  or  attraction. 
On  the  other  hand,  the  desire  need  not  be  an  exclusive  one ;  the 
homosexuality  of  the  psychic  hermaphrodite  constitutes  a  desire 
notwithstanding  the  coexistence  of  an  attraction  toward  the  op- 
posite sex.  Moreover,  where  an  actual  desire  or  proclivity  has 
been  found  to  exist,  it  merits  our  recognition  as  such  quite  as 
much  when  it  is  an  acquired  one  as  it  does  when  it  is  congenital. 


354    THE  UNSOUND  MIND  AND  THE  LAW 

The  question  correctly  formulated  should  be :  In  how  far,  in  an 
individual  instance,  can  the  existing  desire  or  proclivity  be  con- 
sidered pathological?  Krafft-Ebing  is  of  the  opinion  that  a 
pathological  condition  exists  in  all  congenital  cases.  The  group 
in  which  the  homosexual  desire  is  congenital,  however,  is,  in  my 
opinion,  a  very  small  one,  much  smaller  than  we  would  be  led  to 
believe  from  listening  to  the  tales  these  homosexual  individuals 
themselves  tell  of  the  early  recollections  of  their  manifestations. 
As  a  rule,  a  careful  analysis  of  these  recounted  recollections  will 
show  them  to  be  interpretations  of  harmless  juvenile  acts  mostly 
colored  by  subsequent  experiences.  That  some  of  the  more  seri- 
ous cases  are  congenital  and  pathological,  however,  may  be  un- 
reservedly acknowledged;  but  I  am  convinced  that  in  all  of 
these  we  will  be  able  to  discover  other  symptoms  of  mental  dis- 
ease as  well.  I  admit  that  perversion,  particularly  in  its  more 
serious  form,  is  a  symptom  of  disease;  but  I  cannot  admit  that 
of  itself  the  perversion  is  to  be  accepted  as  proof  of  the  existence 
of  mental  disorder.  This  is  entirely  in  accord  with  general  cus- 
tom, which  demands  the  presence  of  a  symptom  complex  before 
a  diagnosis  of  mental  disease  can  be  made.  No  individual  symp- 
tom is  pathognomonic.  This,  it  seems  to  me,  constitutes  the 
vital  point  not  only  in  a  consideration  of  homosexuality,  but  also 
in  the  entire  field  of  psychic  sexual  anomalies. 

We  will  conclude  this  chapter  on  the  anomalies  of  sexual  sense 
by  a  brief  consideration  of  the  treatment  they  receive  under  the 
various  systems  of  punitive  law.  We  have  already  stated  that 
their  significance  from  the  viewpoint  of  civil  law  is  by  no  means 
negligible  and  that  they  very  often  lead  toward  offenses  that 
formally  have  no  relation  whatsoever  to  sexual  things.  I  am  re- 
ferring here  particularly  to  the  different  manner  in  which  the 
individual  legal  systems  look  upon  these  sexual  offenses,  that  is, 
offenses  against  sexual  propriety.  One  main  difference  is  that 
in  some  countries  sexual  excesses  become  the  object  of  legal 
regulation  only  from  the  viewpoint  of  State  care.  Thus  in  France 
anomalous  sexual  acts  are  punished  only  in  so  far  as  they  are 
perpetrated  with  youthful  individuals  or  in  public  or  by  force 
or  threat.  Other  countries  do  not  confine  themselves  to  this 
point  of  view,  but  prosecute  anomalous  sexual  acts  as  such. 
Among  the  latter  countries  we  must  again  differentiate  those 
in  which  sexual  offenses  (unchastity)  between  woman  and  woman 


THE  ANOMALIES  OF  SEXUAL  SENSE    355 

are  completely  ignored  and  only  those  between  man  and  man 
receive  attention;  in  some  countries,  moreover,  unnatural  rela- 
tions between  man  and  woman  are  punishable,  while  in  others 
no  attention  is  given  to  them. 

Far-reaching  differences  finally  will  be  found  in  the  forensic 
appreciation  of  the  subjective  aspect  of  the  acts  that  are  de- 
pendent upon  abnormal  sexual  desires.  In  by  far  most  coun- 
tries legal  culpability  is  excluded  when  mental  disorder  has 
annulled  free  determination.  Under  other  systems,  however,  as, 
for  instance,  that  of  the  State  of  New  York,  responsibility  is 
measured  according  to  the  "right  and  wrong"  test. 

Even  under  the  first-mentioned  system  the  psychopathological 
pervert  may  be  unavoidably  subject  to  undue  harshness,  but 
under  the  last-mentioned  system  punishment  will  be  meted  out 
to  entire  categories  of  individuals  who  on  account  of  disease 
actually  are  free  from  blame,  although  apparently  their  intel- 
lect is  still  unaffected. 


Part  Fourth 

THE  FORMULATION  OF  THE  EXPERT 
OPINION 


PRACTICAL  EXAMPLES 

As  we  have  stated,  the  scope  of  forensic  medicine  is  the  appli- 
cation of  the  facts  of  medicine  and  the  natural  sciences  to  the 
various  fields  of  practical  jurisprudence.  It  devolves  most  par- 
ticularly upon  forensic  psychiatry  to  make  such  reports  that 
the  judge  may  determine  in  each  instance  whether  an  individual 
requires  the  protection  the  law  accords  to  every  person  who  is 
or  was  mentally  irresponsible  or  incompetent.  Whatever  the 
purpose  may  be  for  which  an  expert  opinion  is  demanded,  wheth- 
er it  be  to  determine  a  person's  criminal  responsibility,  his 
civil  liability,  or  his  need  for  a  guardianship  or  internment  in  an 
institution,  the  task  of  the  expert  will  always  be  simply  to  estab- 
lish the  person's  mental  state,  or,  in  other  words,  to  determine 
whether  and  to  what  extent  any  mental  disorder  is  or  was  pres- 
ent. The  psychiatrist  should  bear  in  mind  that  the  fact  that 
the  making  of  a  skilful  diagnosis  in  a  consultation  with  a  num- 
ber of  colleagues  is  an  entirely  different  proposition  from  the 
task  imposed  upon  him  when  he  is  required  to  elaborate  his  opin- 
ion convincingly  in  a  court  of  law.  It  must  be  quite  evident  that 
in  formulating  his  views  before  a  legal  body  he  will  have  to 
express  himself  in  other  language  than  when  talking  to  his  scien- 
tific peers ;  for,  after  all,  from  a  medical  point  of  view,  the  judge 
is  a  layman,  just  as  the  physician  must  be  considered  a  layman 
when  he  is  confronted  with  a  purely  juristic  problem. 

In  order  to  be  able  to  estimate  the  medical  expert 's  exposition 
at  its  true  worth,  the  judge  should  have  at  least  a  general  com- 
prehension of  medical  matters.  Likewise  the  physician  who  pre- 
sents an  opinion  should  at  least  be  conversant  with  the  views 
governing  juristic  actions.  As  a  rule,  the  physician  trained 
only  for  the  actual  practice  of  his  profession  will  determine  all 
states  of  disease  from  the  viewpoint  of  their  curative  treatment. 
In  forensic  psychiatry,  however,  quite  different  considerations 
obtain.  The  application  of  medical,  and  more  particularly  psy- 
chiatric, knowledge  to  questions  of  law  requires  above  all  a  clear 

359 


360    THE  UNSOUND  MIND  AND  THE  LAW 

understanding  of  the  purpose  of  the  law— that  is,  the  physician 
must  know  whether  a  certain  mental  state  is  such  that  a  person 
suffering  therefrom  will  require  the  protection  of  the  law.  Hence, 
the  forensic  psychiatrist  must  be  familiar  to  a  certain  extent  not 
only  with  the  relevant  statutes,  but  also  with  their  often  very- 
diverse  juristic  interpretations.  In  the  construction  of  a  forensic 
expert  opinion,  scientific  arguments  should  be  avoided  as  far  as 
possible.  While  the  discussion  of  academic  questions  may  be 
most  interesting  in  a  scientific  society,  it  is  entirely  out  of  place 
in  a  court  of  law.  The  essential  thing  for  the  judge  to  know  is 
merely  that  the  expert  giving  the  opinion  is  thoroughly  conver- 
sant with  the  details  of  the  science  he  represents.  In  many 
countries  the  only  physicians  allowed  to  testify  as  experts  are 
men  who  are  officially  appointed  to  the  court.  In  other  countries 
it  is  the  usual  procedure  to  select  the  experts  from  among  those 
specialists  who  have  acquired  eminence  in  their  profession.  Hence 
the  judge  will  be  perfectly  justified  in  refusing  to  receive  any 
scientific  disquisition  that  he  can  follow  only  with  difficulty. 

The  expert  opinion  should  not  consist  of  a  detailed  history  of 
the  case,  but  should  be  a  statement  of  facts  so  presented  that 
a  layman  can  obtain  knowledge  of  the  incidents  that  are  deter- 
minative for  the  question  of  mental  responsibility  or  competency. 
Nor  is  it  essential  that  a  definite  diagnosis  be  presented  in  all 
cases.  Many  instances  of  mental  disorder  do  not  represent  dis- 
tinct, definite  types  but  are  made  up  of  pictures  of  degenerate, 
inferior  individuals  whose  morbid  state  is  constantly  changing. 

The  advantages  offered  by  daily  careful  observation  in  an 
institution  are  very  important  for  the  formation  of  an  authori- 
tative opinion.  Yet  in  many  instances  such  observation  is  not 
enough.  Many  of  the  borderline  cases  give  but  slight  evidence 
of  their  peculiarities  and  abnormalities  when  they  are  under  the 
care  and  restraint  of  a  well-governed  institution,  and  the  irregu- 
larities are  manifested  only  when  in  the  struggle  for  existence 
the  defectives  are  obliged  to  attempt  to  adapt  themselves  to  con- 
ditions for  which  they  are  not  fitted.  Consequently  particular 
consideration  must  be  given  to  the  statements  of  relatives  and 
acquaintances  of  the  individual  under  examination.  But  the 
statements  of  the  patient  and  of  his  friends  and  relatives  must 
always  be  carefully  separated  from  the  actual  observations  made 
by  the  expert.     Never  should  a  medical  expert,  as  is  so  often 


PRACTICAL  EXAMPLES  361 

done,  give  a  summary  opinion  that  a  specified  person,  "N.  N." 
is  "normal."  He  should  state  that  he  has  been  unable  to  dis- 
cover any  manifestation  of  disease.  No  purely  summary  state- 
ment, however,  will  be  adequate,  for  what  the  judge  desires  to 
ascertain  is  whether,  and  more  particularly  why,  the  expert  con- 
siders N.  N.  either  mentally  sound  or  mentally  disordered.  For 
th.*  t  reason  the  expert  should  under  all  circumstances  present 
an  opinion  that  is  well  grounded  and  convincing  to  the  court. 

We  shall  now  take  up  a  few  practical  examples  to  illustrate 
the  kind  of  opinion  called  for  under  specific  conditions. 

1.  Guardianship  Proceedings  Instituted  on  Account  op 
Pre-Senile  Dementia 

Proceedings  for  the  appointment  of  a  guardian  for  his  mother, 
Anna  K.,  52  years  of  age,  on  account  of  business  incapacity,  had 
been  instituted,  by  her  son,  Joseph  K. 

The  undersigned,  a  specialist  of  twenty-one  years '  standing  in 
nervous  and  mental  diseases,  was  appointed  to  examine  the  said 
Anna  K.,  and  to  report  in  regard  to  her  mental  condition.  For 
this  purpose  she  was  examined  ten  times  during  the  course  of  a 
month.    The  result  of  my  examination,  in  brief,  is  as  follows : 

From  statements  made  by  Anna  K.  and  her  relatives  I  was 
able  to  obtain  the  following  family  and  previous  history.  Her 
father  had  been  a  heavy  drinker,  and  her  mother  had  died  of 
pulmonary  tuberculosis.  Two  older  brothers  of  Anna  K.  are 
alive  and  healthy.  Though  in  childhood  she  was  weak  and  nerv- 
ous she  was  able  to  keep  pace  with  her  schoolmates  of  similar 
age.  Menstruation  set  in  around  the  sixteenth  year.  With  the 
exception  of  scarlet  fever,  Anna  K.  does  not  recall  having  had 
illnesses  of  any  kind.  She  married  at  the  age  of  twenty-three 
and  bore  two  children,  one  of  which  died  a  few  weeks  after  birth, 
while  the  other,  the  son  Joseph  already  mentioned,  and  now 
twenty-seven  years  of  age,  developed  normally.  A.  K.  denies 
the  habitual  use  of  alcohol  or  narcotics,  and  also  denies  having 
had  any  venereal  infection.  Some  time  ago  the  husband  of  Anna 
K.  had  an  apoplectic  attack,  followed  by  paralysis.  During  this 
illness  she  nursed  her  husband  with  great  devotion  and,  as  a 
result  of  much  loss  of  sleep,  she  soon  became  markedly  exhausted. 
The  description  given  by  her  relatives  would  lead  us  to  conclude 


362    THE  UNSOUND  MIND  AND  THE  LAW 

that  Anna  K.  had  had  a  nervous  attack,  followed  by  a  total  loss 
of  memory  for  recent  events.  This  inability  to  retain  new  im- 
pressions, clearly  noticeable  by  every  one  having  dealings  with 
her,  was  the  immediate  reason  for  questioning  her  mental  in- 
tegrity and  for  the  application  for  the  appointment  of  a  guardian 
on  the  ground  of  incapacity  to  manage  her  business  affairs. 

My  own  observations  enabled  me  to  determine  that  the  memory 
of  Anna  K.  was  very  well  preserved  for  the  remote  past,  even 
for  her  early  childhood,  while  her  memory  for  present  and  recent 
occurrences  was  totally  wanting.  A  more  complete  loss  of  mem- 
ory than  that  found  to  exist  in  Anna  K.  can  hardly  be  imagined. 
Within  a  few  moments  after  she  has  heard  the  name  of  any 
particular  person,  together  with  full  details  of  the  relationship 
existing  between  her  and  that  person,  she  will  have  no  recollec- 
tion whatsoever  of  anything  she  has  been  told,  not  even  the  name. 
This  state  of  her  memory  is  clearly  demonstrated  by  her  conduct 
when  told  of  the  death  of  her  husband.  She  burst  into  a  flood  of 
tears,  then  suddenly  ceased  weeping  and  asked  why  she  had  been 
crying. 

I  examined  her  most  carefully  in  regard  to  her  memory  for 
the  far  past.  Having  lived  in  Germany  as  a  child,  she  was  able 
to  give  the  German  designations  for  every  object  shown  her. 
When  requested  to  do  so  she  could  strike  any  desired  note  on 
the  piano,  and  also  when  any  melody  she  had  formerly  known  was 
played  or  sung  for  her  she  was  able  to  tell  its  name  correctly. 
Her  inability  to  connect  past  impressions  with  one  another  is 
in  no  way  disturbed,  and  by  this  means  she  is  able  to  draw  in- 
ferences and  deductions.  Thus  her  notions  concerning  the  sea- 
son of  the  year  and  the  time  of  day  are  evidently  not  derived 
from  memory  associations,  but  represent  deductions  from  her 
observations.  For  instance,  in  the  afternoon  of  a  day  early  in 
November,  she  was  asked  what  month  it  was.  She  first  looked  at 
the  clock,  then  out-of-doors  and  then  at  the  fireplace.  On  find- 
ing that  the  day  was  drawing  to  a  close  and  seeing  that  most  of 
the  leaves  had  fallen  from  the  trees  and  that  there  was  a  fire 
burning  in  the  fireplace,  she  said  it  must  be  the  end  of  October. 
Five  minutes  later,  when  asked  the  same  question,  she  went 
through  the  same  maneuvers,  drew  the  same  conclusions  and 
gave  the  same  answer. 

Deep  impressions  seem  to  have  quite  as  little  persistence  in 


PRACTICAL  EXAMPLES  363 

her  memory  as  superficial  ones,  nor  could  I  find  that  her  memory 
for  any  one  sense  impression  was  better  than  for  another.  A 
visual  impression  is  forgotten  by  her  quite  as  quickly  as  an 
auditory  one.  Hence  in  Anna  K.  there  exists  a  loss  of  memory 
manifesting  itself  simply  in  an  inability  to  retain  new  impres- 
sions. 

Marked  restriction  of  the  power  of  retaining  new  impressions 
is  a  characteristic  symptom  of  senile  dementia.  This  symptom, 
however,  is  also  present  in  dementia  paralytica,  delirium  tremens 
and  in  other  psychoses.  From  this  symptom  alone,  therefore, 
no  definite  diagnosis  can  be  made.  Further  examination  of  Anna 
K.,  however,  reveals  the  presence  of  still  other  symptoms  which, 
taken  in  connection  with  a  marked  disturbance  of  memory  for 
recent  events,  leaves  no  doubt  that  she  is  suffering  from  a  prema- 
ture senility.  The  patient  is  sullen,  irritable  and  egotistic,  which, 
according  to  statements  made  by  her  relatives,  was  not  formerly 
the  case.  Her  mood  is  predominantly  depressive,  sometimes  apa- 
thetic :  she  is  suspicious  and  reticent,  believes  she  is  being  robbed 
and  that  her  life  is  being  threatened.  Furthermore,  I  was  able 
to  note  that  her  moral  sense  was  decidedly  lowered.  My  own  ob- 
servation, and  this  was  corroborated  by  the  statements  of  others, 
demonstrates  that  she  has  a  tendency  to  act  in  an  immodest  way, 
that  she  is  obscene  in  her  talk  and  that  she  exposes  her  person 
in  the  presence  of  strangers.  Moreover,  many  other  symptoms 
of  senility  are  present.  Although  she  has  by  no  means  reached 
the  period  of  old  age,  she  makes  a  thoroughly  senile  impression. 
She  has  an  opacity  of  the  lens  in  both  eyes,  a  general  motor  weak- 
ness, arteriosclerotic  attacks  of  dizziness  and  faintness,  and  a 
sluggish  reaction  of  both  pupils.  Her  handwriting  shows  the 
characteristic  traits  of  senile  tremor.  Appetite  and  digestion  are 
good,  but  her  sense  of  satiety  seems  to  be  wanting,  for  she  eats 
so  long  as  anything  is  placed  before  her.  This  fact  also  shows 
that  her  memory  for  recent  impressions,  even  when  they  are 
entirely  physical,  is  lacking. 

This  combination  of  symptoms  enables  me  to  express  the  opin- 
ion that  Anna  K.  is  suffering  from  pre-senile  dementia,  the  onset 
of  which  has  been  favored  by  a  neuropathic  heritage  and  by 
over- exertion.  It  is  manifest  that  the  condition  I  have  described 
is  one  that  requires  legal  protection  inasmuch  as  patients  of  this 
kind  are  unable  to  safeguard  their  own  interests.     In  this  con- 


364    THE  UNSOUND  MIND  AND  THE  LAW 

nection,  particular  consideration  should  be  given  to  the  fact  that 
all  scientific  authorities  agree  that  the  prognosis  of  senile  de- 
mentia is  unfavorable.  Patients  of  this  type  who  have  no  mem- 
ory for  recent  events  but  have  desires  and  sensual  wants  are 
likely  to  commit  conspicuously  immoral  acts,  and  when  they  have 
free  control  of  their  own  fortunes  are  liable  to  become  an  easy 
prey  for  all  kinds  of  swindlers  and  adventurers.  In  order  to 
protect  Anna  K.  against  her  own  harmful  acts,  as  well  as  against 
unscrupulous  persons,  she  should  be  placed  under  guardianship. 
An  aggravation  in  her  condition  is  to  be  expected,  and  when 
it  occurs  she  should  be  confined  in  an  institution. 

Dr.  N.  N. 

2.  Infanticide  During  Transitory  Mental  Confusion 

Proceedings  on  account  of  infanticide  having  been  instituted 
against  an  unmarried  factory  girl,  L.  M.,  age  twenty-three,  the 
undersigned  was  requested  by  the  court  to  examine  her  and  to 
give  an  opinion  as  to  whether  at  the  time  the  deed  was  committed 
she  was  suffering  from  any  mental  disorder  that  precluded  free 
determination  on  her  part.  The  previous  history  of  the  case, 
obtained  through  the  District  Attorney,  was  as  follows : 

On  August  21st,  19 — ,  the  District  Attorney's  office  having  re- 
ceived an  anonymous  letter  in  which  the  above-mentioned  L.  M. 
was  accused  of  infanticide,  inquiries  were  instituted  and  it  was 
ascertained  that  she  had  given  birth  to  a  child.  A  detective 
found  the  body  of  the  child,  tied  up  in  a  piece  of  sackcloth,  lying 
under  L.  M.'s  bed.  She  admitted  the  child  was  hers  and  that 
she  had  killed  it  by  cutting  its  throat  with  a  knife.  Thereupon 
she  was  arrested  and  criminal  proceedings  against  her  begun. 
Inasmuch  as  L.  M.  was  born  in  Austria  and  spoke  hardly  any 
English,  all  conversation  had  to  be  conducted  by  means  of  an 
interpreter.    In  this  examination  L.  M.  stated : 

That  on  the  16th  of  August,  19 — ,  at  four  o'clock  in  the  after- 
noon, she  went  to  bed  and  soon  after  gave  birth  to  a  male  child. 
Immediately  after  the  child  had  been  born  she  reached  for  a 
knife  which  had  been  used  for  paring  potatoes  and  which  was 
left  lying  upon  a  nearby  windowsill,  and  with  it  cut  the  child's 
throat.  She  then  placed  the  child  under  the  bedclothes  next  to 
her  own  body.     There  it  lay  until  August  21st.     Whether  the 


PRACTICAL  EXAMPLES  365 

child  was  alive  or  not  when  she  cut  its  throat  she  does  not  know. 
She  did  not  hear  the  baby  emit  any  sound  at  the  time  of  its 
birth  or  afterward.  She  could  not  say  when  she  first  observed 
that  she  was  pregnant.  The  father  of  the  child  was  a  married 
laborer,  "D."  The  knife  was  one  that  had  been  in  daily  use 
and  happened  to  be  within  reach  upon  the  windowsill.  She  had 
committed  the  deed  while  excited  and  it  had  not  been  previously 
planned.  No  sooner  had  the  deed  been  committed  than  she 
deeply  regretted  what  she  had  done. 

The  autopsy  performed  upon  the  body  of  the  child  by  the 
coroner's  physician,  Dr.  S.,  demonstrated  that  the  child  was 
fully  developed  and  viable  and  had  actually  breathed.  The 
cause  of  death  was  a  gaping  wound  that  involved  the  soft  parts 
of  the  neck  and  severed  the  trachea  and  oesophagus.  At  the 
umbilicus  was  found  a  33  centimeter  long  cord,  about  which  a 
string  was  tied. 

At  a  subsequent  inquisition  on  October  5th,  L.  M.  added  state- 
ments to  those  previously  made.  She  said  she  had  made  no 
preparation  for  her  confinement.  It  was  her  first  child  and  she 
had  no  idea  what  to  do.  She  believed  the  child  to  have  come 
too  soon,  because  she  had  a  fall  a  day  previous  to  its  birth.  On 
the  day  of  her  confinement  she  experienced  some  discomfort, 
particularly  abdominal  pains,  and  for  that  reason  remained  away 
from  her  work.  She  remained  at  home  alone  but  without  any 
thought  of  the  impending  birth  of  the  child.  When  the  child 
was  born  she  was  entirely  alone  and  was  beside  herself  with  pain. 
She  then  caught  up  the  knife  and  maintains  she  did  not  know 
until  later  that  she  had  injured  the  baby.  She  furthermore 
states  her  lover  had  deceived  her,  having  told  her  there  was  no 
possibility  of  her  becoming  pregnant.  During  her  pregnancy 
she  gave  no  thought  to  any  such  eventuality,  but  believed  the 
cessation  of  her  menses  to  have  been  due  to  having  caught  cold. 
The  detective,  Sergeant  P.,  testifies  that  he  questioned  friends 
and  acquaintances  of  L.  M.  and  that  none  of  them  had  had  any 
idea  that  she  was  pregnant.  Her  associates  in  the  house  and  her 
sister  claim  not  to  have  noticed  any  change  in  L.  M. 's  appear- 
ance :  even  the  day  preceding  the  confinement  L.  M.  had  spoken 
to  no  one  about  her  pregnancy.  The  previous  day  she  had  had 
a  fall  and  she  gave  a  severe  headache  as  an  excuse  for  her  ab- 
sence from  work. 


366    THE  .UNSOUND  MIND  AND  THE  LAW 

In  the  court  proceedings  on  October  15th,  L.  M.  maintained 
that  she  had  been  so  confused  by  the  pregnancy  and  by  the  birth 
of  the  child  that  she  did  not  know  what  she  was  doing.  She  had 
had  dreadful  pains,  which  rendered  her  distracted  and  she  then 
picked  up  the  knife.  What  she  had  done  with  it  she  ascertained 
later.  At  no  time  had  she  any  idea  that  she  was  pregnant,  nor 
did  she  know  whether  the  child  was  alive  at  any  time  or  not. 
She  had  never  gone  to  school.  After  listening  to  the  testimony  of 
the  expert,  Dr.  O.,  who  stated  that  the  accused  was  mentally 
defective,  the  court  determined  to  have  the  prisoner  placed  under 
observation  in  an  institution  and  the  undersigned  was  appointed 
to  conduct  a  psychiatric  examination  and  to  report  at  the  end 
of  six  weeks.  As  a  result  of  this  examination  I  now  make  the 
following  report: 

My  examination  of  L.  M.  was  begun  on  the  19th  of  October. 
She  went  into  the  ward  of  a  hospital  quietly,  complying  with  all 
requests  and  submitting  freely  to  examination.  The  physical 
examination  gave  the  following  results : 

L.  M.  is  one  hundred  and  sixty -five  centimeters  tall  and  weighs 
sixty-one  kilograms.  Body  temperature  normal,  bony  frame, 
strong,  musculature  tense,  nutrition  fair,  hands  cool  and  moist. 
Measurements  of  the  skull:  Longitudinal  diameter,  17.5  centi- 
meters ;  transverse  diameter,  13.5  centimeters ;  circumference,  53 
centimeters.  Face  fairly  symmetrical.  Skull  claimed  to  be 
somewhat  sensitive  to  pressure  and  percussion.  The  external 
ears  are  well  developed  and  ear  lobes  not  adherent;  mucous 
membranes  somewhat  pale,  pupils  of  medium  diameter,  equal 
with  well-rounded  contours,  reacting  promptly  to  both  light 
and  fixation.  The  eyeballs  are  freely  moved.  The  ocular  fun- 
dus shows  no  pathological  change ;  conjunctival  reflex  is  present : 
facial  musculature  equably  innervated.  Teeth  in  good  con- 
dition. Tongue  protruded  straight,  not  tremulous,  and  moist. 
Palate  high,  palatal  arches  equal,  pharyngeal  reflex  easily  ob- 
tainable, no  tremor  of  the  fingers,  gross  power  of  the  extremi- 
ties equal  on  both  sides.  The  large  nerve-trunks  of  arms  and 
legs  are  claimed  to  be  somewhat  sensitive  to  pressure.  The  ten- 
don reflexes  of  the  upper  extremities  are  easily  obtainable.  The 
mechanical  irritability  of  the  muscles  is  rather  lively.  The  vaso- 
motor lability  (a  red  line  after  stroking)  of  the  skin  of  the  body 
is  slow  and  of  moderate  intensity.    Patellar  reflexes  are  obtained 


PRACTICAL  EXAMPLES  367 

with  difficulty.  A  foot  jerk  cannot  be  elicited,  but  toe  reflexes 
are  normal.  A  touch  with  a  camel's-hair  brush  upon  any  part 
of  the  surface  of  the  body  is  distinctly  felt  and  properly  located. 
A  sharp  instrument  is  clearly  differentiated  from  a  dull  one: 
sensation  to  pain  is  normal.  The  musculature  of  the  calf  of  both 
legs  is  claimed  to  be  sensitive  to  pressure  and  is  somewhat  lax. 
Motility  is  free.  Pulse  seventy-eight,  regular  and  strong.  Heart 's 
sounds  clear.  Lungs  free  from  any  process  of  disease.  The  ab- 
domen is  soft,  can  be  palpated  freely,  but  seems  to  be  somewhat 
sensitive.  The  skin  of  the  abdomen  shows  the  stria  of  recent 
pregnancy.  There  are  no  peculiarities  of  gait.  The  urine  is  free 
from  pathological  constituents.  In  response  to  questions,  L.  M. 
gave  her  name,  age,  place  of  birth  and  many  other  facts  regard- 
ing her  previous  life,  correctly.  Further  observation  resulted  as 
follows : 

During  the  first  few  days  of  L.  M.'s  stay  in  the  hospital,  she 
was  for  the  most  part  inactive.  She  aided  a  little  in  the  work 
about  the  institution,  but  usually  sat  listlessly  looking  out  of  the 
window,  occasionally  turning  the  leaves  of  an  illustrated  maga- 
zine and  appearing  all  in  all  mentally  dull.  Her  mood  was  more 
or  less  equable,  not  depressed  and  rather  indifferent.  At  times 
she  even  seemed  to  be  contented,  smiling  when  addressed  and 
comprehending  the  questions  that  were  put  to  her.  For  instance, 
when  asked  how  she  had  slept,  how  she  was  getting  along,  etc., 
her  reply  always  was  "Very  well."  Asked  what  time  it  was, 
she  promptly  looked  at  the  clock  and  gave  the  correct  answer. 
At  a  subsequent  examination  made  on  October  22d,  she  appeared 
somewhat  dejected,  allowing  her  head  to  hang  forward,  but  she 
responded  willingly  to  questions  asked.  She  said  she  had  pre- 
viously suffered  a  good  deal  from  headaches,  and  that  two  days 
before  the  child-birth  these  headaches  had  been  more  severe.  A 
long  time  ago,  during  the  winter,  she  had  slipped  upon  the  side- 
walk and  had  fallen,  striking  the  back  of  her  head.  Without 
being  questioned,  she  asserted  that  everything  about  her  at  that 
time  had  become  dark  and  she  could  not  see:  nevertheless  she 
had  been  able  to  go  home  unaided.  Since  that  time  she  had 
suffered  from  headaches.  She  had  been  intimate  twice  with  the 
father  of  her  child.  She  was  unable  to  state  when  she  menstru- 
ated last;  she  had  given  no  thought  to  the  possibility  of  being 
pregnant,  merely  believing  her  menses  to  have  been  delayed. 


368    THE  UNSOUND  MIND  AND  THE  LAW 

Her  abdomen,  she  said,  had  not  been  large  enough  to  attract 
attention.  She  admitted  having  seen  women  who  were  pregnant 
and  knowing  that  they  were  pregnant. 

An  attempt  on  October  26th  to  determine  the  amount  of  knowl- 
edge L.  M.  possessed  revealed  that  she  was  able  to  count  cor- 
rectly from  one  to  ten.  She  was  unable  to  read  from  a  written 
page,  but  on  the  other  hand  could  read  German  print  from  a 
page  of  a  book.  Simple  colors  were  designated  by  their  correct 
name.  Objects  shown  her  were  correctly  recognized  and  named. 
An  examination  in  geography  and  history  revealed  a  total  lack 
of  knowledge  of  these  branches. 

In  an  examination  held  on  November  6th  she  again  positively 
maintained  that  she  did  not  know  she  had  been  pregnant  and 
said  she  arose  in  the  morning,  intending  to  go  to  work,  but  re- 
turned to  bed  because  she  felt  sick,  having  pains  in  her  head, 
abdomen  and  the  rest  of  her  body.  She  was  unable  to  state 
accurately  how  long  the  labor  lasted;  she  believed  it  was  two 
to  three  hours.  Abdominal  pains  had  been  present  during  the 
entire  day.  No  one  had  aided  her  during  the  birth  of  the  child. 
What  she  next  did  she  could  not  recall.  Afterward  she  saw  the 
blood  on  the  knife.  Of  what  happened  just  before  that  she 
said  she  knew  nothing.  The  knife  was  lying  within  reach  upon 
the  windowsill:  it  was  not  necessary  to  get  out  of  bed  in  order 
to  obtain  it.  The  placenta  came  away  the  following  day:  she 
had  lost  a  great  deal  of  blood.  After  the  birth  of  the  child 
she  had  washed  herself,  then  wrapped  the  child  in  a  sackcloth 
and  put  it  under  the  bed.  She  had  told  no  one  of  her  act  be- 
cause she  was  afraid.  She  did  not  know  why  she  acted  as  she  did. 
She  had  cleaned  the  knife  and  then  put  it  back  on  the  window- 
sill.  The  next  day  she  got  up  and  went  to  work.  Meanwhile 
the  body  of  the  child  was  lying  under  the  bed.  Whether  any 
one  had  noticed  that  she  was  no  longer  as  large  as  previously 
she  could  not  say :  at  any  rate  she  had  made  no  effort  to  conceal 
her  change  of  form.  The  room  in  which  she  slept  had  been 
occupied  also  by  her  sister,  another  young  girl,  and  a  married 
couple.  No  one  of  these  had  noticed  anything  of  the  labor. 
L.  M.  persisted  in  maintaining  that  after  committing  the  deed 
she  became  so  frightened  that  she  could  not  tell  any  one  what 
had  happened. 

On  November  13th,  on  being  asked  when  she  first  realized  that 


PRACTICAL  EXAMPLES  369 

she  was  pregnant,  she  answered  emphatically,  "I  did  not  at  any 
time  think  I  was  pregnant.  Even  when  the  labor  pain  set  in 
I  did  not  think  of  it."  She  again  maintained  that  no  one  had 
called  her  attention  to  her  enlarged  abdomen  or  to  her  being 
pregnant ;  there  had  never  been  any  talk  regarding  it.  She  had 
never  felt  any  movements  of  the  child.  She  well  knew  the  cause 
for  pregnancy,  but  her  lover  had  assured  her  there  was  no  pos- 
sibility of  such  an  occurrence  in  her  case.  The  cessation  of  the 
menses,  abdominal  enlargement  and  her  unusual  sensations  had 
all  been  attributed  to  other  causes.  "Who  had  cut  the  cord  or 
whether  it  had  been  torn  apart  she  did  not  know,  nor  was  she 
able  to  account  for  the  presence  of  the  knife  upon  the  windowsill. 
It  was  only  later  she  realized  the  child  was  dead,  but  she  did 
not  understand  she  had  killed  it  until  she  noticed  the  blood  upon 
the  knife.  She  had  done  nothing  to  conceal  the  occurrence: 
nevertheless,  even  after  the  birth  of  the  child,  no  one  seemed 
to  have  noticed  anything  unusual,  for  no  one  questioned  her  in 
any  way.  The  afterbirth  she  had  thrown  into  a  ditch  the  follow- 
ing day. 

On  the  17th  of  November  she  made  the  statement  that  some 
years  ago,  while  at  her  own  home,  some  time  during  the  winter, 
she  was  going  to  the  stable,  when  she  slipped  and  fell,  striking 
the  back  of  her  head.  She  had  suffered  much  from  headaches. 
The  day  before  the  birth  of  the  child  she  fell  from  a  wagon.  She 
did  not  lose  consciousness,  but  went  to  work  as  usual.  No  wounds 
of  any  kind  had  been  observed.  She  believed,  however,  that  the 
child  was  prematurely  born  as  a  result  of  this  fall. 

During  the  entire  period  of  institutional  observation  L.  M. 
was  invariably  quiet  and  modest  in  her  demeanor.  After  becom- 
ing accustomed  to  her  new  surroundings  she  occupied  herself  in- 
dustriously with  housework.  In  the  beginning  of  her  stay  she 
was  somewhat  shy  when  spoken  to  and  seemed  embarrassed,  but 
was  always  polite  and  self-controlled.  When  her  work  was  done 
she  would  sit  quietly  in  a  corner,  turning  the  leaves  of  an  illus- 
trated periodical  and  looking  out  of  the  window.  Her  conduct 
toward  nurses  and  other  patients  was  always  unassuming. 
Usually  she  remained  by  herself:  later  another  patient  took  a 
fancy  to  her  and  instructed  her  in  reading  and  writing.  Dur- 
ing such  instruction  she  was  attentive  and  learned  easily.  "When 
the  physician  in  attendance  asked  her  to  show  what  she  had 


370    THE  UNSOUND  MIND  AND  THE  LAW 

learned,  she  appeared  embarrassed,  became  shy  and  at  first 
would  not  write  in  the  presence  of  the  doctor.  After  consider- 
able coaxing,  however,  she  would  do  as  she  was  asked.  Her 
emotional  tone  was  usually  an  equable  one,  and  occasionally  ap- 
parently joyful.  She  smiled  when  she  was  addressed,  and  when 
inquiries  were  made  concerning  her  health  said  she  was  doing 
very  well.  Only  occasionally  did  she  seem  sad :  in  fact,  whenever 
she  was  called  into  the  examining  room  and  questioned  she 
seemed  dejected;  but  she  never  manifested  any  pronounced  de- 
pression. At  odd  times  she  was  temporarily  rather  downcast 
and  upon  one  occasion,  after  reading  a  letter  from  her  sister,  in 
which  reference  was  made  to  their  home,  she  shed  tears.  At 
another  time  when  she  was  dejected,  she  attributed  it  to  repen- 
tance for  what  she  had  done.  Such  states  of  depression  never 
lasted  for  more  than  a  few  hours;  toward  the  end  of  her  stay 
in  the  institution  they  recurred  with  greater  frequency.  Only 
exceptionally  had  L.  M.  complained  of  any  physical  distress. 
According  to  the  statement  of  her  nurse  she  occasionally  com- 
plained of  slight  headaches. 

Upon  another  examination  made  on  November  25th,  the  pa- 
tient was  well  oriented,  able  to  tell  the  day  of  the  week,  and  said 
she  was  feeling  very  well.  She  stated  that  now  she  was  always 
happy.  Asked  why,  if  this  was  so,  she  was  occasionally  found 
crying,  she  sighed  deeply  and  replied  it  was  a  pity  she  had  hurt 
the  child;  aside  from  this,  she  added,  she  had  no  reason  for  be- 
ing unhappy.  She  admitted  that  in  former  times  when  at  home 
she  would  occasionally  take  a  drink  of  whiskey,  but  only  infre- 
quently. 

Based  upon  the  previous  history  and  the  status  prcesens  of 
the  case,  my  opinion  is  that  L.  M.  at  the  present  time  is  not 
insane.  During  the  entire  period  of  observation  in  the  institu- 
tion she  has  conducted  herself  in  an  orderly  manner,  has  shown 
no  disturbance  of  conceptual  powers  nor  of  attention,  and  no 
morbid  emotional  fluctuation.  Her  memory  has  revealed  no  ma- 
terial gaps  with  the  exception  of  the  one  lapse  she  claims  to 
have  had,  namely,  the  one  covering  the  time  of  the  birth  of  the 
child.  As  the  patient  never  attended  school  and  hardly  knew 
the  alphabet,  it  was  most  difficult  to  test  her  intellectual  powers. 
Consequently  we  were  obliged  to  form  an  opinion  of  her  mental 
powers  from  her  general  comportment  during  her  stay  in  the 


PRACTICAL  EXAMPLES  371 

institution  and  from  the  statements  she  made  at  the  various  med- 
ical examinations.  Unfortunately  very  little  information  could 
be  obtained  from  reliable  witnesses  in  regard  to  the  patient's 
mental  state.  The  only  testimony  of  value  we  possess  is  that 
given  by  her  sister,  who  maintains  that  L.  M.  never  showed  any 
peculiarities  of  conduct.  The  only  deduction  that  can  be  drawn 
from  this  statement  is  that  no  pronounced  mental  disorder  could 
have  existed. 

Her  comportment  while  in  the  institution  shows  us  that  in 
L.  M.  there  exists  no  pronounced  feeble-mindedness,  no  distinct 
failure  of  the  mental  faculties.  She  was  not  only  quick  in  com- 
prehending all  questions  asked  her,  but  without  hesitancy  gave 
relevant  replies.  While  we  are  warranted  therefore  in  exclud- 
ing the  existence  of  any  marked  degree  of  feeble-mindedness, 
there  are  present  in  this  patient  certain  traits  which  would  make 
us  consider  her  mentally  different  from  a  perfectly  healthy  in- 
dividual. Especially  noticeable  is  the  fact  that  L.  M.  takes  the 
grave  accusation  made  against  her  rather  lightly,  and  usually 
seems  carefree;  in  fact,  often  even  quite  happy  and  contented. 
Any  sorrow  manifested  by  her  seems  to  be  due  less  to  fear  of 
possible  punishment  than  to  a  longing  for  home  and  relatives. 
Moreover,  her  states  of  depression  were  very  fugacious.  Never- 
theless, the  impression  made  is  not  as  though  her  apparent  un- 
concern were  the  result  of  a  moral  decline,  of  an  indifference  to 
punishment,  but  to  a  lack  of  appreciation  of  right  and  wrong. 

A  factor  of  further  import  in  examining  the  mental  state  of 
L.  M.  is  her  repeated  assertion  that  she  had  not  thought  of  the 
possibility  of  a  pregnancy  because  the  father  of  the  child  had 
assured  her  none  could  exist.  We  must  consider  as  equally 
naive  her  statement  that  she  believed  the  cessation  of  her  men- 
strual period  to  be  due  to  an  abdominal  congestion.  These  state- 
ments, taken  in  conjunction  with  her  invariable  childlike  man- 
ner and  her  equanimity  regarding  any  impending  punishment, 
must  lead  us  to  conclude  that  the  patient  was  mentally  not  com- 
pletely mature,  but  that  her  intellectual  development  had  been 
arrested  and  had  not  progressed  beyond  a  certain  stage  of  child- 
hood. But  even  assuming  the  existence  of  a  certain  mental 
immaturity,  we  are  not  warranted  in  believing  all  the  statements 
made  by  L.  M.  Even  an  immature  child  will  tell  a  falsehood  to 
escape  from  some  unpleasant  predicament.     If  certain  subse- 


372    THE  UNSOUND  MIND  AND  THE  LAW 

quent  statements  of  the  accused  should  prove  to  be  inaccurate 
and  untrustworthy,  our  general  opinion  regarding  her  personal- 
ity would  remain  unaltered;  on  the  other  hand,  we  must  admit 
that  the  immaturity  of  L.  M.  is  not  so  great  as  to  warrant  the 
assumption  of  irresponsibility  for  her  acts  and  conduct  under 
ordinary  conditions  of  life.  In  her  present  state  of  conscious- 
ness L.  M.  is  certainly  perfectly  capable  of  recognizing  the  ille- 
gality and  immorality  of  infanticide  in  general.  On  the  other 
hand,  the  accused  claims  to  have  an  entire  lack  of  knowledge  of 
her  criminal  deed.  At  all  the  judicial  investigations,  as  well  as 
at  the  various  medical  examinations,  she  has  always  maintained 
that  she  had  been  confused  and  benumbed  by  her  pains,  that 
she  did  not  know  what  she  had  done  and  that  it  was  only  later 
that  she  noticed  the  mutilated  body  of  the  dead  child. 

A  question  to  be  answered,  therefore,  is  whether  any  evidence 
exists  that  would  prove  the  criminal  act  not  to  have  been  com- 
mitted while  the  accused  was  in  a  state  of  pathologically  dis- 
ordered consciousness.  Such  twilight  states,  when  present,  most 
frequently  exist  upon  an  epileptic  or  hysterical  basis.  In  this 
instance  we  have  no  indication  justifying  the  assumption  of  the 
existence  of  epilepsy,  nor  have  we  any  proof  of  the  existence  of 
hysteria.  The  only  person  who  could  give  us  any  information  in 
this  regard  is  the  sister  of  the  accused,  and  she  maintains  that 
she  never  noticed  anything  peculiar  about  her.  During  the  en- 
tire period  of  observation  L.  M.  never  made  the  impression  of 
being  an  hysteric.  We  are  not  warranted,  therefore,  in  assum- 
ing the  existence  of  an  hysterical  twilight  state.  Nevertheless, 
in  view  of  the  fact  that  since  the  fall  upon  her  head  the  patient 
suffers  from  frequent  apparently  causeless  attacks  of  headache 
and  dizziness,  we  are  justified  in  attributing  to  her  a  neurotic 
predisposition.  This  assumption  is  borne  out  by  our  clinical 
observation,  notwithstanding  that  the  statements  of  the  patient 
are  not  corroborated  by  any  other  evidence.  Thus  my  first  physi- 
cal examination  revealed  a  sensitiveness  of  the  skull,  of  the  nerve 
trunks  and  of  the  muscles,  which  did  not  make  the  impression 
of  being  simulated  or  exaggerated.  Whether  the  accident,  the 
fall  from  a  wagon  upon  the  day  before  the  child  was  born,  had 
exerted  a  deleterious  influence  upon  this  nervously  predisposed* 
individual  cannot  be  determined  with  certainty.  But  even  if 
we  assume  the  existence  of  a  certain  neurotic  predisposition,  we 


PRACTICAL  EXAMPLES  373 

are  riot  warranted  in  concluding  that  the  patient  was  suffering 
from  a  mental  disorder  and  an  inhibition  of  free  determination 
at  the  time  of  the  commission  of  the  deed. 

Therefore,  in  the  absence  of  all  indications  warranting  the 
assumption  of  the  existence  of  an  epileptic  or  hysteric  twilight 
state,  we  must  determine  whether  disorders  of  consciousness  may- 
occur  during  parturition  and  be  dependent  upon  this  process 
alone  in  the  absence  of  any  other  symptom  of  disease.  This  ques- 
tion should  be  answered  affirmatively.  That  the  physical  exhaus- 
tion produced  by  labor  pains,  the  concomitant  loss  of  blood  and 
circulatory  disturbances  in  the  maternal  organism  may  all  cause 
a  certain  alteration  of  psychic  activity,  must  be  perfectly  evident. 
Moreover,  it  is  also  certain  that  the  mental  anguish  to  which  an 
unmarried  pregnant  woman  would  be  exposed  as  a  result  of  her 
shame,  fear  and  helpless  situation,  may  have  an  additional  influ- 
ence upon  her  psychic  state.  Usually  the  alterations  of  psychic 
activity  resulting  from  labor  are  not  so  intense  as  to  produce  any 
manifest  clouding  of  consciousness.  There  are  certain  well- 
known  individual  exceptional  cases,  however,  in  which  women 
who  were  previously  entirely  healthy  were  rendered  uncon- 
scious by  the  pains  of  parturition ;  and  occasional  cases  of  tran- 
sitory delirium  produced  by  the  same  cause  in  women  who  were 
physically  healthy  have  also  been  reported.  The  possibility  of 
the  occurrence  of  such  transitory  mental  disorders  will  be  ad- 
mitted all  the  more  freely  when  we  recall  that  it  is  by  no  means 
unusual  for  states  of  mental  confusion  to  be  produced  by  severe 
psychic  shock  in  persons  who  have  previously  been  considered 
healthy.  In  the  case  of  a  parturient  unmarried  woman,  however, 
the  aforementioned  factors  of  bodily  exhaustion  and  physical 
pain  are  reinforced  by  those  of  mental  distress. 

Leaving  these  generalities  and  asking  ourselves  whether  as 
a  matter  of  fact  the  accused  did  suffer  from  a  transitory  state 
of  confusion,  we  must  acknowledge  that  a  positive  medical  deci- 
sion cannot  be  given.  We  have  no  witnesses  who  could  give  us 
any  information  regarding  the  condition  of  the  accused  at  the 
time  of  the  confinement.  No  judicial  hearing  could  be  instituted 
until  five  days  afterward,  and  no  medical  examination  until  six 
weeks  afterward.  Therefore,  in  determining  the  mental  state 
of  L.  M.,  at  the  time  of  the  birth,  we  are  dependent  entirely 
upon  her  credibility.    Such  determination  of  credibility  is  essen- 


374    THE  UNSOUND  MIND  AND  THE  LAW 

tially  a  legal  and  not  a  medical  question.  Nevertheless,  we  are 
warranted  in  calling  attention  to  the  fact  that  none  of  the  actions 
of  the  accused  indicates  simulation  on  her  part,  but  that,  on  the 
contrary,  in  all  examinations  she  has  made  the  impression  of 
being  frank  and  perhaps  even  naive.  Moreover,  we  should  not 
lose  from  sight  the  following  considerations: 

Confusional  states  occurring  at  the  time  of  parturition  are  of 
great  rarity  in  previously  healthy  women.  Although  L.  M.  does 
not  suffer  from  any  pronounced  mental  disorder,  she  cannot  be 
said  to  be  physically  entirely  normal,  for  we  have  already  shown 
that  there  exists  in  the  accused  a  slight  nervous  predisposition 
and  a  childlike  nature,  a  certain  mental  immaturity  and  hence 
also  probably  a  mild  degree  of  enfeebled  judgment. 

Medical  experience  teaches  that  such  deviations  may  easily 
constitute  the  basis  for  psychoses,  particularly  for  transitory 
mental  disturbances  that  arise  in  the  train  of  external  irritations, 
bodily  as  well  as  mental.  This  furnishes  us  with  a  firm  ground- 
work for  the  assumption  that  the  deed  committed  by  L.  M.  may 
have  been  carried  out  in  a  state  of  pathologically  altered  con- 
sciousness. However,  it  is  noteworthy  that  the  statements  of  the 
accused  at  no  time  contradict  one  another.  All  her  assertions, 
whether  made  during  the  proceedings  in  court,  or  during  the 
individual  medical  examinations,  agreed  in  all  essential  points. 

While  we  would  not  be  warranted  in  assuming  that  all  her 
assertions  are  true  because  they  have  been  the  same  on  all 
occasions,  yet  it  is  remarkable  that  they  bear  no  contradiction  to 
each  other  in  certain  material  points,  and  her  description  of  her 
psychic  state  corresponds  perfectly  to  a  confusional  state  known 
to  psychiatry.  It  is  not  at  all  probable  that  an  uneducated  and 
entirely  immature  person  could,  from  her  own  consciousness, 
evolve  a  description  of  a  typical  form  of  disease.  The  fact  that 
the  accused  became  frightened  after  she  had  committed  the  deed 
and  therefore  concealed  the  body  of  the  child  and  disposed  of 
the  afterbirth,  notwithstanding  that  she  may  have  considered 
her  offense  a  pardonable  one  and  notwithstanding  that  the  deed 
had  not  been  a  premeditated  one,  are  acts  which  in  a  person  of 
a  low  order  of  intelligence  should  not  astonish  us.  Nor  does  the 
statement  of  the  accused  that  she  felt  remorse  for  what  she  had 
done  preclude  the  assumption  of  mental  disorder.  It  must  in- 
deed be  considered  remarkable  that  L.  M.  did  not  realize  she 


PRACTICAL  EXAMPLES  375 

was  pregnant  when  she  noticed  her  increasing  abdominal  girth, 
particularly  so  in  view  of  her  admission  that  she  was  familiar 
with  the  appearance  of  pregnant  women.  On  the  other  hand, 
it  is  possible  that  the  changes  in  her  form  were  not  so  marked 
and  that  L.  M.,  credulous  as  she  was,  might  not  have  attributed 
them  to  other  causes.  That  these  changes  in  form  were  not  very 
noticeable  may  be  assumed  to  have  been  the  case,  inasmuch  as 
after  her  confinement  no  one  seems  to  have  observed  any  altera- 
tion in  her  figure.  Moreover,  so  far  as  can  be  ascertained,  the 
accused  did  not  speak  to  any  one  concerning  her  pregnancy  and 
certainly  did  not  mention  her  impending  confinement,  not  even 
to  her  sister.  Apparently,  also,  she  did  not  make  the  slightest 
preparation  for  the  coming  event,  and  she  even  worked  about 
the  house  upon  the  day  the  baby  was  born.  Furthermore,  if  we 
take  into  consideration  the  accident  that  occurred  the  day  prior 
to  the  confinement  we  may  assume  that  the  birth  of  the  child 
was  unexpected. 

Under  such  circumstances  we  can  easily  comprehend  that 
L.  M. 's  emotional  excitement,  her  sudden  fear  of  things  that 
were  about  to  occur,  her  feeling  of  utter  helplessness  and  de- 
sertedness,  and  her  despair  on  account  of  her  lover's  deception 
should  have  been  of  the  utmost  intensity. 

We  will  also  understand  that  in  the  absence  of  any  skilled  at- 
tention, even  if  L.  M.  had  hitherto  been  a  person  of  good  physical 
and  mental  health,  without  any  neuropathic  taint,  her  physical 
sufferings  may  have  been  so  pronounced  as  to  cause  an  acute 
mental  disturbance.  Finally,  during  the  entire  time  L.  M.  was 
under  observation  she  never  gave  any  evidence  of  cruelty,  cun- 
ning or  ethical  deficiency,  so  that  purely  psychological  consider- 
ations would  lead  us  to  assume  that  her  state  of  consciousness 
during  the  perpetration  of  the  deed  must  have  been  an  altered 
one. 

In  conclusion,  in  view  of  the  difficulties  the  case  presents,  I 
would  again  emphasize  the  fact  that  a  positive  determination 
cannot  be  reached.  "While  a  consideration  of  all  the  points  that 
have  a  bearing  upon  L.  M.'s  mental  state  forces  us  to  the  con- 
clusion that  she  is  not  insane  at  the  present  time,  it  is  quite  pos- 
sible, and  even  probable,  that  at  the  time  she  killed  her  new-born 
child  she  was  in  a  state  of  confusion  which  precluded  all  free 
determination  on  her  part.  (Signed)   Dr.  N.  N. 


376    THE  UNSOUND  MIND  AND  THE  LAW 

3.  Theft  Committed  in  a  State  of  Paretic  Mental 
Enfeeblement 

The  case  of  J.  B.,  a  coachman,  45  years  of  age,  married,  against 
whom  criminal  proceedings  were  pending  on  account  of  theft, 
was  referred  to  the  undersigned  for  an  expert  opinion.  After 
repeated  examination  of  the  patient  and  a  careful  study  of  the 
case,  it  is  my  opinion  that  J.  B.,  at  the  time  of  the  commission  of 
the  deed,  was  in  a  disordered  mental  state,  that  for  a  long  time 
he  had  been  suffering  from  dementia  paralytica,  that  no  im- 
provement in  his  condition  is  to  be  expected  and  that  the  mental 
disorder,  which  is  dependent  upon  a  progressive  involvement 
of  the  central  nervous  system,  at  present  annuls  any  voluntary 
determination  on  his  part.    This  condition  will  continue  to  exist. 

According  to  the  judicial  reports,  J.  B.,  according  to  his  own 
admissions,  committed  various  burglaries  between  the  twenty- 
eighth  of  July  and  the  ninth  of  September,  1911 ;  other  thefts 
of  which  he  has  been  accused  he  denies  having  committed.  He  is 
able  to  give  fairly  complete  information  in  regard  to  the  thefts 
which  he  admits,  but  it  is  quite  evident  his  orientation  in  regard 
to  the  time  of  the  occurrences  of  these  acts  is  very  inaccurate. 
For  instance,  he  is  unable  to  give  the  sequence  of  these  thefts 
and  he  does  not  know  the  location  of  the  residences  and  stores 
that  were  burglarized  by  him.  Moreover,  he  can  give  but  very 
inadequate  information  concerning  the  objects  he  stole.  Having 
been  told  that  his  statements  in  regard  to  the  purloinment  of  a 
bicycle  appeared  improbable,  because  the  date  he  had  given  did 
not  accord  with  the  date  of  the  theft,  he  said:  "I  have  said  it 
was  so  because  I  assume  that  date  to  be  correct.  I  cannot  be 
more  precise,  I  thought  I  was  right."  It  was  also  noteworthy 
that  he  made  no  effort  whatever  to  excuse  his  punishable  acts. 
' '  I  was  without  employment, ' '  he  says,  ' '  and  then  a  person  wan- 
ders about  and  the  idea  came  to  me.  I  had  no  fear.  I  thought 
nothing  about  it.  When  I  think  of  one  thing  I  forget  every- 
thing else." 

The  previous  history  of  the  case  is  as  follows: 

After  a  syphilitic  infection  in  1900  the  patient  in  1905  com- 
plained of  attacks  of  dizziness  and  diplopia,  but  these  were  not 
followed  by  any  serious  disorder  and,  being  of  infrequent  occur- 
rence and  short  duration,  apparently  did  not  interfere  in  any 


PRACTICAL  EXAMPLES  377 

way  with  his  feeling  of  health  and  his  working  capacity.  In  the 
spring  of  1907  a  state  of  irritable  depression  set  in  and  this  cul- 
minated in  a  suicidal  attempt.  The  accused  went  to  an  out-of- 
the-way  place  with  the  intention  of  taking  his  own  life,  then  tem- 
porarily gave  up  the  idea  and  slept  soundly  in  a  lodging-house 
distant  from  his  own  home,  but  the  following  day  he  did  make 
the  premeditated  suicidal  attempt.  These  attendant  circum- 
stances in  themselves  would  indicate  the  existence  of  some  mental 
enfeeblement. 

There  are  present,  however,  other  evident  signs  of  psychic  de- 
fect associated  with  symptoms  of  disease  of  the  central  nervous 
system.  J.  B.  had  been  under  medical  care  and  had  been  dis- 
charged as  cured.  A  month  after  his  discharge,  however,  he 
applied  for  readmission  into  a  hospital,  on  the  ground  that  he 
had  traveled  a  long  distance  upon  a  trolley  car  without  any 
definite  purpose  and  without  knowing  where  he  was  going.  After 
being  in  the  institution  a  month  he  refused  to  remain  any  longer, 
saying  he  was  discontented  and  felt  no  better.  Then  followed 
a  period  of  general  fatigue,  irritability  and  sleeplessness,  during 
which  he  was  unable  to  work.  In  July,  1908,  he  again  undertook 
a  senseless  wandering,  and  much  of  what  occurred  at  this  time 
had  entirely  escaped  from  his  memory.  This  incident  alarmed 
him  so  that  he  sought  readmission  to  the  institution.  After  a 
short  sojourn  there,  which  brought  improvement,  he  left  of  his 
own  accord.  He  seems  to  have  felt  well  thereafter  and  to  have 
been  able  to  work  until  May,  1909,  when  without  reason  he  gave 
up  a  good  position,  obtained  employment  elsewhere  and  after 
a  week  returned  to  his  former  place,  begging  to  be  taken  back. 
After  that  he  worked  in  various  places  with  success.  Within 
two  years,  however,  his  condition  had  grown  manifestly  worse, 
and  it  was  then  that  he  committed  the  thefts  which  led  to  his 
being  arrested  while  he  was  endeavoring  to  pawn  some  of  the 
stolen  goods.  The  accused  seems  to  have  a  certain  realization  of 
his  mental  defect,  and  expresses  this  insight  by  the  following 
words :  "I  no  longer  have  the  sense  nor  the  memory  I  formerly 
had."  Thus  appropriately  characterizing  the  decline  that  has 
taken  place  in  his  emotional  and  intellectual  life. 

His  wife,  describing  the  conduct  of  the  accused  during  the 
months  preceding  his  arrest,  says  her  husband  had  been  most 
irritable,  had  sought  to  seclude  himself,  was  indifferent  and  slept 


378    THE  UNSOUND  MIND  AND  THE  LAW 

a  great  deal  during  the  daytime,  even  when  his  sleep  the  previous 
night  had  been  undisturbed.  She  had  also  noticed  that  he  had 
become  forgetful.  Moreover,  she  had  been  told  by  a  physician 
that  her  husband  was  very  nervous. 

J.  B.  could  give  but  a  most  imperfect  estimate  of  the  length 
of  time  he  had  been  under  medical  treatment,  and  he  could 
not  tell  the  age  of  his  wife,  nor  the  year  of  his  marriage.  His 
statements  regarding  his  occupation  were  very  uncertain  and 
were  made  only  after  long  reflection.  His  weakness  of  memory 
became  evident  when  his  knowledge  of  things  acquired  by  rote 
was  tested.  Only  after  much  thought  and  calculation  could  he 
tell  how  much  six  times  eight  or  three  times  nine  was.  The  most 
simple  geographical  and  historical  facts  had  escaped  his  mem- 
ory. His  answer  to  such  questions  was  always :  "  I  do  not  know ; 
I  knew  it  once,  but  I  have  forgotten  it. ' '  His  defect  of  memory, 
however,  covers  not  only  knowledge  previously  acquired,  but 
things  mentioned  to  him  very  recently.  He  was  asked  to  repeat 
certain  words,  numbers,  etc.,  and  his  attention  was  called  to  ob- 
jects of  various  kinds,  but  after  the  lapse  of  a  few  moments 
he  was  unable  to  state  what  numbers  and  which  objects  had 
been  mentioned.  In  addition  he  was  but  imperfectly  oriented 
in  regard  to  time,  and  particularly  also  in  regard  to  simple 
conceptual  associations.  For  instance,  when  asked  to  repeat  a 
short,  simple  story,  he  related  it  in  such  a  senseless  manner  that 
it  was  very  plain  he  could  not  have  understood  the  story  at  all. 
Likewise,  when  asked  to  deduce  similarities  and  differences  from 
any  general  concept,  he  failed  completely ;  for  instance,  he  could 
not  explain  the  difference  between  a  hill  and  a  mountain,  be- 
tween a  shrub  and  a  tree,  etc.  Physically,  a  sluggish  pupilary 
reaction  to  light,  articulatory  speech  disorder  and  increased  knee 
jerks  could  be  demonstrated.  His  facial  traits  are  lax.  Upon 
the  skin  of  the  lower  extremities  his  sensibility  to  pain  was  re- 
duced.   His  handwriting  was  clumsy. 

Summing  up  the  facts  derived  from  his  previous  history  and 
from  observation,  it  seems  certain  that  J.  B.  committed  his  un- 
lawful deeds  while  in  a  state  of  mental  weakness  which  had  ex- 
isted prior  to  the  commission  of  these  deeds,  which  is  still  present 
and  which  will  continue  to  increase.  This  mental  weakness  is 
caused  by  dementia  paralytica,  the  characteristic  symptoms  of 
which  are  present.     From  medical  experience  we  know  that  a 


PRACTICAL  EXAMPLES  379 

cure  or  even  any  permanent  improvement  is  not  to  be  expected. 
On  the  contrary,  as  the  disease  progresses  the  patient  will  become 
more  and  more  demented.  Individuals  so  afflicted  may  become  a 
menace  to  themselves  and  to  their  surroundings,  and  for  this 
reason  I  recommend  that  J.  B.  be  placed  under  permanent  super- 
vision in  some  institution. 

(Signed)  Dr.  N.  N. 

4.   Felonious  Assault  During  a  State  op  Induced 
Insanity 

On  December  18th,  a  former  janitor,  G.  K.,  seventy-nine  years 
of  age,  and  his  unmarried  daughter,  A.  K.,  both  accused  of 
felonious  assault,  were  placed  for  observation  in  a  psychopathic 
ward  and  the  undersigned  was  requested  to  examine  them  and 
furnish  an  expert  opinion  regarding  their  mental  state.  Upon 
the  basis  of  a  study  of  their  previous  history  and  observation 
covering  a  period  of  six  weeks,  I  have  arrived  at  the  opinion  that 
the  deed  of  which  these  persons  are  accused  was  committed  while 
they  were  in  a  state  of  induced  insanity,  that  G.  K.  and  his 
daughter,  A.  K.,  suffer  from  ideas  of  persecution,  and  that  at 
the  time  of  the  commission  of  the  deed,  at  present  and  also  for 
the  future  there  appears  to  be  no  question  of  any  free  determina- 
tion on  their  part. 

From  the  history  of  this  case  we  learn  that  G.  K.  and  his 
daughter  made  an  attack  upon  B.  H.,  an  inmate  of  the  same 
house,  while  he  was  going  upstairs.  The  father  pinioned  the 
victim 's  arms  while  his  daughter  struck  him  over  the  head  with  a 
club  until  his  cries  brought  a  number  of  people  to  his  rescue 
and  he  was  taken  unconscious  and  bleeding  to  the  hospital.  The 
aggressors  were  arrested  and  taken  to  the  police  station.  Accord- 
ing to  statements  made  by  other  inmates  of  the  house,  in  which 
G.  K.  and  his  daughter  had  lived  for  a  long  time,  they  had 
shown  such  marked  excitability  as  to  arouse  a  suspicion  that  they 
were  mentally  unsound.  In  the  police  station,  too,  their  conduct 
was  such  as  to  create  a  doubt  as  to  their  normal  responsibility. 
The  history  of  G.  K.  is  as  follows : 

He  is  a  widower  and  for  a  number  of  years  has  been  living 
with  his  unmarried  daughter,  who  keeps  house  for  him.  The 
anamnesis  reveals  nothing  special  pertaining  to  the  occurrence 


380    THE  UNSOUND  MIND  AND  THE  LAW 

of  psychoses  or  psycho-neuroses  in  the  family.  The  man 's  mother 
died  in  childbirth  and  his  father  of  old  age.  G.  K.  himself,  born 
in  Ireland,  learned  to  walk  at  the  proper  time  and  had  no  con- 
vulsions or  injuries  of  any  kind.  His  former  employers  and  his 
friends  and  acquaintances  speak  well  of  him,  praising  his 
conduct,  his  faithfulness,  conscientiousness  and  stability  of 
character. 

Physically  G.  K.  is  a  robust,  white-haired  man,  strong  and 
well  nourished.  He  appears  to  be  much  younger  than  is  actually 
the  case.  Aside  from  a  moderate  emphysema  and  bronchitis, 
physical  examination  reveals  no  disorder.  There  is  no  manifest 
arteriosclerosis  of  the  peripheral  vessels.  The  radial  arteries 
are  not  tortuous  and  the  pulse  is  of  normal  tension.  The  pupils 
are  equal  in  size  and  react  promptly.  The  patellar  reflexes  are 
easily  obtainable ;  there  is  no  Babinski  and  no  Romberg.  Cortico- 
motor  and  sensory  apparatus  show  nothing  unusual.  Speech 
and  handwriting  are  not  disordered,  nor  does  this  latter  reveal 
the  existence  of  any  tremor.  Examination  of  the  organs  of 
special  sense  discloses  merely  a  moderate  degree  of  presbyopia 
and  slight  deafness.  Physically  G.  K.  is  completely  oriented  in 
regard  to  place,  time  and  persons  and  is  able  to  recall  each  single 
happening  that  led  to  his  arrest  and  to  his  transfer  to  the  asylum. 
When  received  in  the  institution,  as  well  as  during  the  entire 
period  of  his  stay,  his  behavior  was  perfectly  peaceable  and 
orderly.  He  is  quiet  at  night.  The  occurrence  of  confusional 
states,  even  of  a  transitory  nature,  has  never  been  noticed. 

Questioned  regarding  his  delusions  and  hallucinations,  he 
makes  statements  which  reveal  the  existence  of  a  connected  sys- 
tem of  false  beliefs  and  gives  an  account  of  persecution  and 
intrigues  to  which  he  alleges  he,  and  above  all,  his  daughter,  have 
been  exposed,  insisting  with  emphasis  that  B.  H.  is  the  originator 
of  these  persecutions.  The  cause  to  which  he  attributes  them  is  a 
refusal  on  the  part  of  his  daughter  to  permit  B.  H.  to  take  undue 
familiarities  with  her.  Entirely  spontaneously  he  asserts  that  it 
was  his  daughter  who  had  called  his  attention  to  B.  H.  as  being 
the  person  who  had  planned  and  started  the  persecutions  and 
intrigues  to  which  they  both  had  been  subjected.  He  maintains 
that  B.  H.  has  incited  all  the  people  in  the  house  against  him  and 
his  daughter  and  that  a  woman,  Mrs.  L.,  had  called  his  daughter 
a  common  thing  and  said  it  was  a  shame  to  have  such  people  in 


PRACTICAL  EXAMPLES  381 

the  house:  also  that  other  people  of  the  neighborhood  were 
inimical  to  them  and  that  these  were  disreputable  persons  who 
had  been  influenced  by  that  man  B.  H.  They  had  always  looked 
askance  upon  him  and  his  daughter,  having  accosted  them  in  the 
street  and  called  them  vile  names.  The  people  living  above  them 
in  the  house  had  moved  in  for  the  sole  purpose  of  annoying  them 
by  means  of  all  kinds  of  noises,  in  order  to  force  them  to  seek 
other  quarters.  B.  H.  had  been  absent  from  New  York  for  a 
time  and  during  this  period  there  had  been  no  annoyances.  Then 
the  persecutions  began  again.  A  number  of  persons  had  united 
in  order  to  act  against  him  and  his  daughter.  He  had  heard  two 
women  talking  about  them  in  the  house,  he  said,  and  although 
they  mentioned  no  names  he  had  known  they  referred  .to  him  and 
his  daughter  when  they  said,  "For  thirty  dollars  we  can  do  that. 
You  will  get  twenty  and  I  will  get  ten. ' '  Charges  of  theft  had 
been  brought  against  his  daughter,  he  added.  All  of  the  wit- 
nesses were  perjurers  with  the  exception  of  one  girl,  who  told 
the  truth  and  who  for  that  reason  was  discharged  from  the  posi- 
tion she  held.  The  following  quotations  from  his  writings  are 
characteristic : 

"This  man  B.  H.  had  annoyed  me  for  two  years  at  least,  be- 
cause my  daughter  would  not  entertain  his  insulting  proposi- 
tions. He  has  said  he  would  give  me  no  rest  until  I  moved  from 
the  house.  My  daughter  has  been  sick  for  two  years  on  account 
of  the  continuous  annoyances  to  which  we  have  been  subjected. 
Our  letters  are  read  aloud  in  the  public  streets,  and  a  speaking 
tube  or  telephone  has  been  installed  in  the  third  story  above  us  in 
order  that  our  conversations  may  be  heard.  Even  the  private 
conversations  we  had  with  our  physician  have  been  repeated  on 
the  streets. ' ' 

Notwithstanding  numerous  assurances  of  the  post-office  author- 
ities and  the  telephone  people  that  his  accusations  were  ground- 
less, J.  K.  persisted  in  writing  letters  to  both  of  these.  Further- 
more he  says,  "I  also  complained  that  letters  belonging  to  me 
were  put  into  boxes  of  other  people,  while  letters  not  belonging 
to  me  were  placed  in  my  box.  The  letter  carrier  has  assured  me 
that  he  knows  the  name  of  the  person  who  has  committed  these 
irregularities,  ,but  may  not  mention  his  name.  I  then  told  him 
no  one  else  could  have  done  these  things  but  B.  H.  and  I  knew 
that  he  took  the  letters  out  of  the  box  by  means  of  a  wire  hook. 


382     THE  UNSOUND  MIND  AND  THE  LAW 

To  this  the  letter  carrier  made  no  reply.  My  daughter  had  told 
me  that  whenever  she  goes  out  she  is  followed  by  private  de- 
tectives and  one  of  these  she  recognized  as  a  person  whom  she 
had  formerly  known.  Sometime  ago,  I  sent  my  daughter  to  Mrs. 
T.  in  order  to  obtain  some  information:  when  she  returned  the 
forefinger  of  one  of  her  hands  was  bleeding.  Asked  how  this 
had  happened  she  replied  that  when  Mrs.  T.  shook  hands  with 
her  she  at  once  felt  her  finger  pricked  and  then  it  began  to  bleed. 
This  constitutes  another  proof  of  the  persecutions  to  which  my 
daughter  is  subjected.  Furthermore  I  have  often  heard  the 
children  in  the  house  speaking  of  "that  beast,"  which,  of  course, 
could  mean  only  me.  I  know  positively  that  these  children  have 
been  urged  to  do  this  by  B.  H.  My  daughter  has  also  told  me 
that  B.  H.  notifies  the  police  of  her  going  out  every  time  she 
leaves  the  house.  Once  upon  opening  the  door  of  my  dwelling  I 
noticed  the  maid  of  B.  H.  standing  in  front  of  the  door  listening : 
she  then  rapidly  walked  upstairs  and,  turning  around,  put  her 
tongue  out  at  me.  Another  time  we  noticed  a  rope  let  down  from 
B.  PI.  's  apartment  in  front  of  our  kitchen  window  in  order  that 
we  might  hang  ourselves  upon  it.  I  have  had  B.  H.  followed  and 
watched  by  detectives,  but  they  have  been  unable  to  find  any 
proof  against  him.  In  all  probability  he  has  bribed  the  de- 
tectives." 

These  extracts  from  G.  K.  's  writings  will  suffice.  As  a  matter 
of  fact  he  had  engaged  detectives  and  spent  considerable  money 
for  such  services. 

A  test  of  the  intelligence  of  G.  K.  shows  that  he  possesses  a 
good  school  knowledge  and  that  his  store  of  memory  pictures  and 
their  associative  connections,  as  well  as  their  sequence  as  to  time, 
is  well  preserved.  Questions  regarding  the  recent  past  are  cor- 
rectly answered ;  his  arithmetical  knowledge  is  good ;  his  multi- 
plication, division  and  subtraction  are  rapid  and  correct.  In  so 
far  as  the  special  examination  of  his  mental  capabilities  is  con- 
cerned, no  defect  was  revealed  in  a  test  of  his  attentiveness  and 
particularly  of  the  retroactive  associations,  the  lack  of  which, 
according  to  present  knowledge,  would  be  characteristic  of  de- 
mentia senilis  and  dementia  arteriosclerotica.  A  test  of  his 
memory,  particularly  for  form  and  words  associated  in  pairs, 
showed  good  results,  even  when  a  considerable  interval  was  al- 
lowed to  intervene.     On  the  other  hand,  a  test  of  his  power  of 


PRACTICAL  EXAMPLES  383 

combination  showed  a  defect  of  judgment,  although  not  of  high 
degree.  At  any  rate  this  defect  of  judgment  is  not  so  great  as  to 
warrant  the  deduction  that  a  senile  enfeeblement  of  mind  exists. 

In  this  case  of  G.  K.,  therefore,  we  find  upon  the  one  hand  a 
man  who,  having  no  hereditary  taint,  has  remained  bodily  and 
mentally  apparently  healthy  into,  an  advanced  age,  has  always 
shown  himself  orderly  and  quiet  and  then  commits  an  act  of  vio- 
lence ;  but  who,  upon  the  other  hand,  discloses  a  system  of  delu- 
sions of  persecution  and  depreciation  which  have  so  distorted 
his  relations  to  the  outer  world  that  he  assumes  the  existence  of 
conditions  which  as  a  matter  of  fact  do  not  prevail. 

Let  us  now  take  up  the  history  of  the  girl.  A.  K.  was  born 
without  the  use  of  instruments,  she  passed  through  the  ordinary 
diseases  of  childhood  and  never  had  any  convulsions.  When 
one  year  of  age  she  sustained  a  fracture  of  the  femur,  but  never 
had  any  noteworthy  injury  to  her  skull.  The  anamnesis  given 
by  her  father,  which  must  be  received  with  caution,  because  he 
gave  it,  discloses  that  she  developed  well,  was  always  cheerful 
and  obedient,  but  was  occasionally  obstinate.  After  leaving 
school  she  took  up  dressmaking  and  earned  her  living  by  this 
means.  In  the  year  1904  she  lost  her  position,  and  since  then 
has  devoted  herself  to  the  care  of  her  father's  household,  which 
she  is  said  to  have  conducted  in  a  thoroughly  competent  and 
careful  manner.  She  went  into  society  but  very  little,  and  her 
father  had  noticed  that  for  four  or  five  years  she  had  been  more 
or  less  of  a  recluse.  The  reason  that  she  gave  for  this  was  that 
she  did  not  wish  people  to  make  fun  of  her.  Of  late  years  she 
had  complained  of  constant  fatigue  and  had  attributed  it  to  the 
care  she  had  given  her  sister  during  a  prolonged  illness. 

Dr.  S.,  who  had  been  the  family  physician  for  a  long  time, 
makes  the  following  statement  regarding  A.  K. : 

"As  long  as  I  have  known  her  she  has  been  uncompanionable 
and  suspicious,  always  seeking  some  hidden  meaning  in  every 
word  and  getting  into  constant  friction  with  her  associates  and 
the  people  of  the  house.  When  her  father  felt  in  any  way  indis- 
posed or  when  he  complained  of  rheumatic  pains,  she  would  al- 
ways accuse  some  one  of  purposely  creating  a  draught  by  leaving 
a  window  or  door  open.  In  this  way  she  always  sought  to  hold 
some  one  else  responsible  for  her  father's  sickness.     She  spoke 


384    THE  UNSOUND  MIND  AND  THE  LAW 

in  a  monotonous,  disconnected  manner,  as  though  she  would  fall 
asleep  in  the  middle  of  a  sentence. ' ' 

Dr.  S.  believes  that  during  the  last  few  years  she  was  becom- 
ing increasingly  childish  and  foolish.  She  conducted  the  house- 
hold with  care  and  attention,  however,  fulfilling  all  her  father's 
wishes.  She  was  always  anaemic.  From  May  until  June,  1909, 
she  suffered  from  severe  angina  and  influenza  and  from  that 
time  on  could  not  be  induced  to  leave  her  bed.  After  a  nurse 
had  been  placed  in  charge  things  went  somewhat  better :  hardly 
had  the  nurse  left,  however,  when  she  fell  back  into  a  state  of 
apathy,  and  this  was  interrupted  finally  by  the  attack  made  upon 
B.  H.  At  the  end  of  July,  1909,  it  was  determined  to  send  her 
to  a  sanatorium,  but  she  refused  to  go,  and  preferred  to  consult 
fortune  tellers,  Christian  Scientists  and  hypnotists.  Whether 
she  suffered  from  delusions  at  that  time  cannot  be  determined. 
While  in  the  observation  ward  of  the  hospital  the  following 
status  was  taken: 

Patient  is  a  small  person,  well  nourished,  but  of  somewhat  anae- 
mic appearance.  Her  facial  expression  is  indifferent  and  apa- 
thetic. Her  sensory  and  motor  apparatus  give  no  evidence  of  dis- 
order. No  hysterical  stigmata,  nothing  special  in  regard  to  her 
internal  organs.  Patient  lies  in  bed  relaxed,  showing  no  interest  in 
her  surroundings  and  does  not  alter  her  posture  even  when  the 
physician  approaches  the  bed.  She  extends  her  hand  in  greeting 
in  an  affected  manner,  merely  touching  the  hand  that  is  proffered 
her.  Her  replies  to  questions  are  given  in  a  weak,  monotonous 
and  somewhat  lachrymose  voice.  She  is  fully  oriented  in  regard 
to  place,  time  and  persons.  The  statements  she  makes  in  regard 
to  her  previous  life  correspond  accurately  with  the  information 
that  had  been  obtained  from  other  people.  Questioned  in  regard 
to  her  hallucinations  she  gives  a  description  of  the  scandalous 
things  that  had  been  said  about  her  and  of  the  persecutions  and 
intrigues  to  which  she  and  her  father  had  been  subjected,  em- 
ploying about  the  same  words  that  her  father  had  previously 
used.  She  says  people  passing  her  house  at  night  would  stop 
and  call  her  vile  names.  Once,  while  visiting  a  family  living  in 
the  same  house  with  her,  she  was  given  some  coffee,  and  after- 
ward she  became  nauseated  and  vomited  throughout  the  entire 
night.  People  are  listening  on  the  telephone  to  everything  she 
says,  and  she  is  being  influenced  by  means  of  hypnotism  and 


PRACTICAL  EXAMPLES  385 

electricity.  In  all  the  stores  she  is  treated  very  badly  and  is 
obliged  to  pay  higher  prices  for  goods  than  any  one  else. 

When  I  visited  her  on  December  20th,  1909,  A.  K.  lay 
apathetically  in  bed  with  eyes  closed,  as  though  she  were  asleep, 
but  keeping  the  bedclothes  away  from  her  body  with  her  hands. 
At  times  she  was  in  a  very  lachrymose  mood,  yet  always  without 
the  manifestation  of  any  deep  emotion.  At  one  time  she  would 
complain  of  headaches,  at  another  of  pain  in  the  stomach  and 
then  of  sleeping  poorly.  Nevertheless  she  cannot  be  induced  to 
take  narcotics  nor  to  have  moist  applications  made  to  her  abdo- 
men. She  also  complains  of  being  neglected  and  receiving  no 
treatment,  and  complains  particularly  about  her  food,  finding 
fault  with  one  thing  after  another.  Her  actions  are  childish  and 
foolish  and  she  asks  in  an  infantile  voice,  ' '  How  is  my  papa  ?  Is 
my  papa  not  yet  dead  ?  Is  my  papa  still  alive  ? "  It  is  only  with 
difficulty  that  she  can  be  induced  to  leave  her  bed  and  go  out  of 
doors. 

During  the  night  of  February  9th,  1910,  she  became  very  noisy, 
could  not  be  kept  in  bed  and  gave  evidence  of  great  fear  and 
anxiety.  Asked  about  the  cause  of  her  fears,  she  said  her  father 
was  to  be  killed,  then  that  she  was  hearing  voices  of  men,  then 
again  voices  of  women.  She  really  could  not  say  whether  this 
was  imaginary  or  real.  Since  she  had  been  in  this  institution 
she  had  not  been  feeling  so  well.  It  seemed  as  though  she  were 
attached  to  the  bed  and  could  not  get  out  even  if  she  so  desired. 
She  heard  voices  telling  her,  "After  two  weeks  you  may  go  out 
again."  It  seemed  as  though  the  voices  came  from  the  hall. 
Probably  she  was  being  influenced  by  hypnotism,  she  said,  but 
how  this  was  done  she  did  not  know. 

On  February  19th,  1910,  the  patient  complained  of  hearing 
constant  voices  indicating  some  one  was  shooting.  She  asked  ap- 
prehensively who  was  being  killed  and  whether  her  father  was 
dead.  She  then  threw  herself  upon  the  floor  and  kicked  her  legs 
like  a  little  child.  Having  been  induced  to  dress  herself  and  to 
go  out  into  the  yard  she  at  once  began  to  undress  in  the  open  air. 

On  February  23rd,  the  patient  did  not  react  to  any  salutation 
or  address.  She  lay  in  bed  quietly  as  though  asleep,  but  when 
some  one  was  leaving  the  room  she  called  in  a  foolish  tone,  "  Is  it 
true  that  my  papa  is  still  alive  ? ' '  The  following  day  the  nurse 
reported  that  during  the  night  A.  K.  had  soiled  her  bed  repeat- 


386     THE  UNSOUND  MIND  AND  THE  LAW 

edly.  She  was  very  restless,  constantly  moving  about,  saying  a 
great  misfortune  had  overtaken  her  and  again  complaining  that 
she  must  die.  When  the  nurse  came  to  her  later  she  did  not 
budge  and  gave  no  answer.  When  her  breakfast  was  brought  she 
refused  to  eat  it :  when  it  was  being  taken  away  she  hastily  seized 
it,  but  did  not  eat.  When  the  physician  visited  her  she  was  at 
first  taciturn  and  then  began  to  complain,  saying  that  she  could 
not  endure  the  voices.  If  she  remained  in  bed,  these  voices 
called  to  her,  ' '  Why  didn  't  you  get  up  ?  "  and  when  she  got  up 
they  called,  "Why  don't  you  remain  in  bed?"  Her  excitement 
became  greater  and  greater.  She  clung  to  the  physician's  arm 
and  called  despondently,  "I  have  not  insulted  any  one.  I  am 
here  in  my  own  bed.  Why  do  you  want  me  sent  to  prison  for 
life  ? ' '  She  kept  on  asking,  ' '  What  has  happened  ?  Who  has  been 
shooting  ?    Is  my  father  dead  ? ' '    Gradually  she  became  quieter. 

The  following  day  the  patient  was  completely  apathetic,  re- 
fused all  nourishment  and  had  to  be  fed.  She  violently  opposed 
any  attempt  that  was  made  to  have  her  use  the  bed  pan.  Then 
for  days  she  lay  immobile,  with  closed  eyes,  apathetically,  in  the 
old  stereotyped  position. 

In  a  long  written  composition  furnished  by  her  father  and 
bearing  the  date  1909  she  described  minutely  and  connectedly 
the  persecutions  to  which  she  had  been  subjected  and  her  descrip- 
tion corresponded  in  every  way  with  that  given  by  her  father. 
On  account  of  negativistic  conduct  it  was  not  possible  to  carry 
out  an  accurate  intelligence  test. 

If  the  facts  given  in  these  two  histories  be  now  subjected  to 
critical  analysis,  we  find  two  persons,  father  and  daughter,  simul- 
taneously brought  into  the  observation  ward  of  an  insane  asylum 
and  accused  of  a  criminal  act,  evidently  committed  while  they 
were  insane.  The  first  question  to  be  answered  is,  What  rela- 
tionship, if  any,  exists  between  the  psychoses  of  father  and 
daughter?  Are  we  dealing  with  a  disease  which  is  accidentally 
contemporaneous  and  similar,  or  is  there  any  causal  connection 
between  the  two  psychoses? 

As  far  as  the  father  is  concerned  we  would  first  think  of  a 
primary  chronic  paranoia.  This  idea,  however,  is  controverted 
by  the  advanced  age  of  the  patient.  We  know  that  his  system  of 
delusions  did  not  set  in  acutely,  but  was  created  gradually  as  a 
result  of  his  associational  activities.    But  if  we  place  the  date  of 


PRACTICAL  EXAMPLES  387 

the  beginning  of  the  psychosis  back  ten  years,  for  at  that  time 
G.  K.  was  undoubtedly  mentally  unaffected,  we  would  still  have 
an  age,  sixty -nine  years,  at  which  the  occurrence  of  a  paranoia  is 
very  improbable.  From  a  differential  diagnostic  point  of  view 
we  would  then  have  to  consider  whether  we  might  not  be  dealing 
with  persecutory  delusions  occurring  in  the  course  of  a  senile 
dementia.  Delusions  of  persecution  as  well  as  delusions  of  in- 
jury do  occur  during  such  senile  mental  enfeeblement  and  the 
patients  then  believe  themselves  to  be  robbed,  slandered  by  their 
neighbors,  etc.  These  delusions,  however,  are  very  sparse,  con- 
fused and  unrelated.  Hardly  ever  is  there  a  further  elaboration 
of  the  delusions,  a  transformation  of  the  contents  of  conscious- 
ness into  hallucinations.  This  is  explained  by  the  fact  that  in 
old  people  the  association  processes  in  general  are  less  mobile  and 
extended. 

In  the  previous  history  of  G.  K.,  therefore,  and  particularly  in 
the  results  obtained  from  an  intelligence  test,  there  are  absent 
all  those  symptoms  which  would  warrant  us  in  making  a  diag- 
nosis of  senile  dementia  and  which  would  justify  us  in  assuming 
the  existence  of  senile  persecutory  delusions.  The  memory  pic- 
tures, particularly  those  for  the  more  recent  past,  are  intact; 
neither  the  memory  for  recent  events,  nor  the  retroactive  associ- 
ations, whose  early  involvement  is  characteristic  of  senile  mental 
enfeeblement,  show  any  disorder  whatsoever.  The  coherence  of 
the  conceptual  processes  is  intact.  On  the  other  hand,  a  test  of 
the  patient's  power  of  conception  reveals  a  slight  degree  of 
weakness  of  judgment,  which,  however,  does  not  warrant  the  as- 
sumption of  a  dementia.  What  we  do  see,  and  this  is  very  im- 
portant, is  that  this  enfeeblement  of  judgment  has  produced  an 
orderly  and  connected  system  of  delusions.  While  the  feeble- 
minded may  construct  a  delusional  edifice,  the  existing  intelli- 
gence defect  would  prevent  it  from  becoming  systematized. 
Hence,  senile  dementia  may  also  be  excluded  in  G.  K. 

In  going  over  the  history  of  father  and  daughter,  we  are  im- 
pressed by  the  fact  that  we  have  in  this  instance  all  the  condi- 
tions necessary  for  the  induction  or  transmission  of  a  psychosis 
from  one  person  to  another.  We  have  above  all  an  extraor- 
dinarily intimate  association  between  the  two  affected  persons. 
Both  have  lived  in  almost  complete  seclusion  from  the  outer 
world,  thus  becoming  entirely  dependent  upon  each  other  and 


388    THE  UNSOUND  MIND  AND  THE  LAW 

precluding  that  critical  analysis  through  which  erroneous  ideas 
could  have  been  corrected.  Moreover,  they  had  full  opportunity 
to  occupy  themselves  constantly  with  their  own  thoughts,  to 
communicate  them  to  each  other,  and  thus  to  enable  each  to  con- 
tribute to  the  delusional  structure. 

That  their  delusions  were  completely  identical  has  been  stated. 
It  would  be  difficult  to  find  a  more  pregnant  sample  of  a 
folie  a  deux.  If  we  consider  further  that  the  daughter  occupies 
the  center  of  the  entire  delusional  system,  and,  as  shown  by  the 
statement  of  the  father,  that  few  observations  were  made  by  him- 
self, but  almost  all  emanated  from  the  daughter,  we  will  have 
found  the  thread  that  connects  the  two  psychoses,  and  without 
difficulty  we  will  arrive  at  the  conclusion  that  the  daughter's 
delusional  ideas  became  implanted,  fixated  and  elaborated  upon 
the  moderate  degree  of  senile  enfeeblement  of  judgment  that 
existed  in  the  father. 

That  the  daughter  was  first  affected  is  shown  by  the  previous 
history.  Moreover,  the  symptom  complex  as  manifested  in  her, 
particularly  the  lack  of  emotion,  the  stereotypy,  the  mannerisms, 
the  foolish  childish  actions,  must  lead  us  to  believe  that  in  her 
there  existed,  possibly  from  puberty,  a  paranoid  form  of  de- 
mentia precox,  but,  of  course,  we  find  no  external  signs  of  this 
manifested  in  the  father.  It  need  hardly  be  stated  that  the 
transmission  of  a  psychosis  in  its  entirety  from  one  person  to 
another  would  be  contrary  to  the  teachings  of  all  psychiatric 
experiences.  The  father,  in  consequence  of  his  senile  weakness  of 
judgment,  has  adopted  the  delusion  of  the  daughter. 

It  is,  therefore,  my  opinion  that  the  criminal  act  of  which 
G.  K.  and  his  daughter,  A.  K.,  are  accused,  was  committed  under 
the  influence  of  delusions  of  persecution,  which  existed  at  the 
time  of  the  commission  of  the  deed  and  which  still  exist.  The 
prognosis  in  the  case  of  the  daughter  is  entirely  unfavorable.  In 
the  case  of  the  father  it  is  doubtful.  Both,  being  deprived  of 
their  free  determination,  should  be  placed  under  institutional 
care.  (Signed)  Dr.  N.  N. 

5.    Simulation  of  Insanity 

G.  R.,  48  years  of  age,  unmarried,  barber  by  occupation,  a 
resident  of  New  York  City,  was  arrested  on  the  5th  of  March. 


PRACTICAL  EXAMPLES  380 

While  in  prison  his  conduct  was  so  extraordinary  that  doubt' 
arose  as  to  his  responsibility.  On  April  3rd,  the  undersigned 
was  requested  to  examine  him  and  to  report  in  regard  to  his 
condition. 

My  observations  were  spread  over  a  period  of  six  weeks.  I 
now  render  my  opinion  that  G.  R.,  although  degenerate  and 
defective,  committed  the  criminal  acts  of  which  he  is  accused 
while  in  a  state  of  consciousness  and  without  any  disorder  of 
mental  activity  which  would  exclude  his  free  determination. 

G.  R.  was  born  in  Germany  and  was  an  illegitimate  child.  He 
came  to  America  in  his  twenty-seventh  year.  We  have  but  an 
inaccurate  report  regarding  his  family  conditions  and  his  early 
life,  for  we  are  dependent  entirely  upon  his  own  assertions,  and 
their  trustworthiness  is  not  great.  According  to  his  own  state- 
ment he  is  hereditarily  mentally  tainted,  inasmuch  as  a  number 
of  members  of  his  family  have  been  afflicted  with  mental  dis- 
order. His  paternal  grandfather  is  said  to  have  been  a  drinker, 
his  grandmother  suffered  from  melancholia  and  committed  sui- 
cide, and  a  brother  of  his  mother,  on  account  of  religious  differ- 
ences, killed  a  girl  to  whom  he  was  engaged.  Another  relative  of 
his  mother  is  said  to  have  hanged  himself  during  an  attack  of 
insanity;  a  sister  of  his  mother  is  said  to  have  been  feeble- 
minded ;  his  mother  herself  was  an  exceedingly  excitable  woman 
with  whom  it  was  very  difficult  to  get  along.  The  accused  de- 
veloped well  physically  and  did  not  suffer  from  any  noteworthy 
disease.  When  two  years  of  age  he  received  a  blow  on  his  head 
which  left' a  scar  that  is  still  plainly  visible  but  which  produced' 
no  other  disorder.  He  attended  the  public  schools  and  is  said  to 
have  learned  well  and  easily.  After  leaving  school  he  was  ap- 
prenticed to  a  barber. 

From  that  time  until  he  emigrated  to  America  he  held  various 
positions.  He  was  excused  from  military  service  on  account  of 
his  defective  vision.  According  to  his  own  statement  his  em- 
ployers generally  were  satisfied  with  him  in  the  beginning,  but 
gradually  became  discontented  because  they  exaggerated  slight 
errors  that  he  committed.  He  began  to  drink  and,  for  this  reason, 
finally  lost  his  place.  A  probably  more  trustworthy  explanation 
is  given  in  the  certificate  he  brought  with  him  from  the  author- 
ities in  Germany,  in  which  we  read :  "  G.  R.  was  active  in  many 
positions,  in  all  of  which  he  made  a  satisfactory  beginning,  but 


390    THE  UNSOUND  MIND  AND  THE  LAW 

after  a  short  time  was  discharged  on  account  of  drunkenness  and 
ensuing  delinquency."  G.  R.  himself  states  that  at  that  time  he 
drank  not  only  when  in  company,  but  also  a  great  deal  when 
alone. 

The  police  records  show  that  while  in  a  state  of  drunkenness 
he  repeatedly  committed  acts  of  violence  and  infractions  against 
property.  Further  inquiry  in  his  own  home  shows  that  G.  R. 
had  been  repeatedly  punished  and  was  known  to  the  police  as  a 
careless,  quarrelsome  inebriate,  who  was  constantly  in  debt  and 
had  repeatedly  obtained  money  under  false  pretenses.  For  the 
latter  offense  he  had  once  been  sentenced  to  six  weeks'  imprison- 
ment. He  acknowledged  the  debt  in  all  its  details,  but  denied 
any  false  pretense  in  having  obtained  the  money.  Soon  after  his 
release  he  was  again  sent  to  prison  for  three  months  on  account 
of  swindling  and  a  few  months  later  was  again  accused  of  a 
similar  offense.  It  would  appear  that  for  some  years  preceding 
his  emigration  he  lived  entirely  by  such  schemes.  In  conse- 
quence of  his  distaste  for  work  he  earned  little,  but  he  always 
drank  a  great  deal.  "SVhen  he  could  not  meet  his  obligations  he 
would  promise  to  come  back  to  his  creditors  the  following  day, 
but  he  actually  disappeared  never  to  show  up  again. 

After  these  occurrences  G.  R,  took  steps  to  escape  the  conse- 
quences of  his  criminal  acts  by  simulating  insanity.  In  the 
prison  cell  he  tore  the  bed  coverings  to  pieces  and  when  called 
to  account  he  said,  "At  night  a  man  always  comes  into  my  cell 
and  gets  into  bed  beside  me.  I  can  never  get  hold  of  him,  other- 
wise I  would  have  knocked  him  to  pieces  long  ago. ' '  He  sent  a 
letter  to  the  judge,  in  which  he  maintained  that  he  was  "men- 
tally dead  while  his  body  could  not  keep  pace  with  his  spirit." 
His  death,  he  added,  was  in  some  way  connected  with  a  cousin, 
who  was  living  in  America,  and  who  had  appointed  him  his  suc- 
cessor in  business,  to  go  into  effect  when  the  necessary  trans- 
formation in  him  should  have  taken  place.  His  cousin,  he  wrote, 
wished  to  place  himself  in  communication  with  him.  and  for  this 
d  he  begged  the  court  to  discharge  him  from  prison.  After 
the  metamorphosis  had  been  accomplished,  he  stated  he  would 
propose  some  social  and  religious  reform  by  means  of  which 
many  questions  would  be  solved  and  permanent  happiness  be 
given  to  the  world. 

Under  questioning,  the  prisoner  expounded  similar  ideas  and 


PRACTICAL  EXAMPLES  391 

claimed  to  have  visions  of  various  kinds,  among  others  those  of 
little  black  men  w  ith  glowing  eyes.  During  the  medical  examin- 
ation he  refused  to  sit  down  on  the  chair,  saying  he  would  be 
electrocuted  if  he  did  so.  He  characterized  his  experiences  as 
extraordinary  and  hardly  credible,  but  explained  that  he  had 
satisfied  himself  of  the  actuality  of  his  visions  by  throwing 
things  at  the  objects  he  saw.  He  dated  the  commencement  of  the 
change  that  had  taken  place  in  him  to  a  year  before,  saying  that 
since  then  he  had  gradually  lost  his  eyesight  and  his  memory  and 
had  become  mentally  dull.  It  was  about  that  time  that  the  prison 
physician  gave  the  following  written  opinion  regarding  the  man's 
mental  state : 

"We  must  admit  that  the  psychic  picture  presented  by  the 
patient  at  the  time  of  examination  conforms  entirely  with  the 
typical  picture  of  a  well-justified  mental  disease  which  we  desig- 
nate as  primary  insanity  or  paranoia,  and  which  is  characterized 
in  the  main  by  the  perceptual  power  of  a  person  becoming  af- 
fected and  controlled  by  systematized  delusions,  so  that  the  con- 
sciousness of  self  and  of  the  surrounding  world  undergoes  a 
complete  falsification  and  displacement.  Inasmuch  as  all  this 
seems  to  have  occurred  in  the  accused,  we  must  above  all  ask  our- 
selves whether  the  picture  of  disease  presented  in  this  patient  is 
actually  a  genuine  one  and  whether  the  nonsensical  assertions  he 
makes  must  be  looked  upon  as  actual  delusions.  In  so  doing  we 
must  remember  above  all  that  while  persons  who  endeavor  to 
simulate  any  mental  disorder  usually  conduct  themselves  in  as 
remarkable  and  insane  a  manner  as  possible,  G.  E.  on  the  con- 
trary during  the  entire  period  of  observation  has  behaved  in  a 
very  quiet  and  unassuming  way.  As  a  matter  of  fact,  he  has  al- 
ways been  quiet  and  composed  and  has  never  attempted  to  simu- 
late a  state  of  general  mental  confusion.  He  gives  all  informa- 
tion regarding  his  personality  as  well  as  regarding  his  antece- 
dents perfectly  correctly  and  accurately  and  always  replies  re- 
spectfully to  all  questions  that  do  not  touch  upon  his  delusions ; 
nor  does  he  ever  impose  his  delusions  upon  the  people  about  him, 
but  mentions  them  only  when  questioned  or  in  his  written  pro- 
ductions. 

"So  far  as  these  delusional  concepts  themselves  are  concerned, 
they  do  not  manifest  themselves  as  isolated  formations,  but 
clearly  bear  a  causal  relationship  to  sense  deceptions  of  all  kinds 


392  THE  UNSOUND  MIND  AND  THE  LAW 

and  to  abnormal  sense  perceptions,  just  as  seems  to  be  the  rule 
in  hallucinatory  forms  of  insanity.  Moreover,  the  fact  that  R. 
suffers  from  hallucinations  and  illusions  in  various  sensory  do- 
mains is  corroborated  by  the  experiences  he  claims  to  have  had. 
We  are  furthermore  able  to  follow  the  gradual  development  of 
R. 's  originally  purely  sensory  delusions  into  a  general  delusion 
of  grandeur,  which  now  proclaims  itself  in  the  shape  of  the  most 
astonishing  ideas  for  the  improvement  of  the  world.  From  the 
notion  that  he  is  already  dead  and  now  has  entered  upon  a 
spiritual  association  with  other  spirits,  the  further  delusion  has 
undoubtedly  developed  in  R.  that  he  is  perfectly  able  in  his  pres- 
ent state  to  see  clearly  the  relationship  and  connection  of  all 
things  and,  therefore,  should  be  able  to  reform  all  existing  social 
and  religious  conditions. 

' '  Hence,  we  see  that  in  R.  there  has  developed  a  perfect  delu- 
sional system  in  which  each  delusion  merely  represents  a  link  in 
a  continuous  chain.  The  simulation  of  such  a  picture  seems 
hardly  possible.  If  to  all  this  be  added  the  circumstances  that  R. 
undoubtedly  comes  from  a  psychically  tainted  family  and  for  a 
long  time  has  been  a  heavy  drinker,  we  have  sufficient  facts  to 
warrant  us  in  assuming  the  existence  in  the  accused  of  an  actual 
mental  disease  and  to  determine  our  belief  that  he  is  not  simu- 
lating. I,  therefore,  state  my  opinion  that  R.  is  actually  suffer- 
ing from  a  pathological  disorder  of  mental  activity  (primary 
hallucinatory  insanity),  as  a  result  of  which  his  free  determina- 
tion has  been  annulled.  From  all  the  facts  at  my  disposal,  I 
would  assume  that  the  accused  was  insane  at  the  time  he  com- 
mitted the  criminal  acts." 

I  have  considered  it  necessary  to  cite  this  opinion  by  the  Ger- 
man investigator  in  full  in  order  to  show  how  even  an  experi- 
enced psychiatrist  may  be  deceived  by  an  adept  trickster.  As  a 
rule  the  exposure  of  such  simulation  is  not  difficult.  The  prem- 
ise for  successful  simulation  is  the  wilful  production  of  certain 
symptoms  which,  in  their  entirety,  may  represent  concrete  forms 
of  mental  disease.  The  knowledge  of  the  intimate  relationship 
between  these  manifestations  of  disease  can  be  gained  only 
through  experience  which  the  simulant  usually  does  not  possess. 
There  are  persons,  however,  who  have  often  had  opportunity 
carefully  to  observe  the  insane  or  who  have  acquired  from  books 
an  intimate  knowledge  of  insanity.    These  may  prove  exceptions 


PRACTICAL  EXAMPLES  393 

to  the  rule,  but  usually  the  picture  of  disease  produced  by  the 
simulant  does  not  correspond  to  any  definite  form  of  mental  dis- 
ease, but  consists  only  of  actions  that  to  a  layman  would  seem 
to  be  those  of  an  insane  person. 

A  healthy  person  attempting  to  copy  a  maniacal  state  will  soon 
succumb  to  the  fatigue  connected  with  the  permanent  motor  ex- 
citement, while  the  real  maniac  will  not  be  at  all  conscious  of 
fatigue.  Or  else  the  simulator,  believing  himself  incapable  of 
coping  with  the  exertion  necessary  for  acting  the  part  of  a 
maniac,  may  endeavor  to  simulate  a  stupor,  not  knowing  that  the 
accurate  representation  of  such  a  state  demands  an  indifference 
and  lack  of  emotion  that,  notwithstanding  the  greatest  self- 
control,  it  is  practically  impossible  to  counterfeit. 

In  a  case  of  this  sort  the  healthy  person  either  overdoes  or 
underdoes :  he  omits  something  that  is  necessary  in  order  to  com- 
plete an  accurate  picture  of  the  disease  or  else,  in  order  to  ap- 
pear insane,  he  exaggerates.  The  resulting  inconsistencies  will 
disclose  the  simulation.  Occasionally,  however,  even  the  trained 
physician  will  become  the  dupe  of  an  adroit  simulator,  of  one 
who  has  understood  how  to  play  his  role  with  dramatic  talent  and 
to  adapt  his  actions  to  the  altered  state  of  consciousness  that  ex- 
ists in  the  disease  he  is  copying.  Such  deceptions  may  be  ex- 
plained by  the  fact  ,that  not  all  psychoses  are  associated  with 
demonstrable  physical  changes  by  means  of  which  psychic  dis- 
ease may  be  diagnosticated  with  certainty.  Such  physical 
changes  (absence  of  reflexes,  unequal  pupils,  etc.)  cannot  be 
simulated,  of  course,  and  when  they  are  present  there  need  be 
no  suspicion  of  simulation.  On  the  other  hand,  it  is  very  possible 
that  the  physical  examination  will  be  a  negative  one,  will  give 
normal  results,  and  nevertheless  actual  mental  disease  be  present. 
To-day  we  well  know  that  health  and  disease  blend  unnoticeably, 
one  into  the  other,  so  no  sharp  demonstration  between  them  can 
be  made.  The  possibility  must  always  be  considered  that  the 
particular  disease  with  which  we  are  dealing  cannot  be  grouped 
in  a  certain  class.  That  fact  alone,  however,  would  not  warrant 
us  in  assuming  the  disease  to  be  a  simulated  one  for,  after  all,  we 
may  be  dealing  with  a  disease  which  as  yet  we  do  not  know  how 
to  classify.  Hence,  while  a  symptom  complex  that  will  not  fit 
into  the  clinical  picture  of  any  known  disease  may  appear  to  be 
decidedly  artificial,  actual  disease  may  be  present.    Furthermore, 


394    THE  UNSOUND  MIND  AND  THE  LAW 

the  majority  of  psychiatrists  are  agreed  that  mentally  healthy 
persons  very  rarely  become  simulators  while  degenerates  and  in- 
ferior individuals  have  a  marked  tendency  to  simulation.  In  the 
latter,  just  as  in  children,  the  play  of  the  imagination  forces  it- 
self into  the  circle  of  actual  happenings  either  transitorily  or 
permanently — and  falsifies  the  recollection  of  their  actual  per- 
sonal experiences.  The  perceptual  play,  so  to  say,  escapes  the 
control  of  the  simulator,  and  what  in  the  beginning  was  conscious 
and  purposeful  deception  under  the  liability  of  the  consciousness 
of  self,  gradually  becomes  a  pathological  swindle  and  forms  still 
another  uninhibited  impulse  for  deception.  Then,  of  course,  it 
never  can  be  said  with  complete  certainty  just  where  conscious 
simulation  ceases  and  where  the  morbid  mental  state  of  the  simu- 
lant dominates. 

I  have  gone  into  this  detail  in  order  to  explain  how  even  at 
the  present  time  a  trained  observer  may  mistake  a  real  psychosis 
for  simulation,  or  on  the  contrary  may  take  simulation  to  be  an 
actual  psychosis.  In  the  above  recorded  opinion  regarding  the 
accused,  G.  R.,  the  expert,  following  the  psychiatric  rules  of  pro- 
cedure, has  taken  into  consideration  all  the  attendant  circum- 
stances and  has  paid  particular  attention  to  the  entire  personal- 
ity of  R.  Nevertheless  his  opinion  proved  to  be  an  erroneous 
one.  As  a  result  of  this  opinion  R.  was  declared  irresponsible,  the 
proceedings  against  him  were  annulled  and  he  was  placed  in  an 
insane  asylum.  The  examination  in  the  institution  revealed  no 
physical  disorders.  R.  was  quiet  and  occupied  himself  in  read- 
ing, complained  a  great  deal  of  lonesomeness  and  in  general  ex- 
pressed the  same  delusions.  Nevertheless  after  a  prolonged  ob- 
servation, the  following  conclusion  was  reached : 

"  R.  is  a  drinker ;  so-called  pathological  states  of  drunkenness 
have  not  been  observed ;  on  the  contrary,  R.  is  very  sly  and  wary 
and  seems  to  be  able  to  utilize  conditions  and  persons  well  for  his 
own  advantage.  It  is  very  doubtful  whether  the  delusions  to 
which  he  gave  expression  and  the  paranoid  hallucinations  he 
claims  to  have  had  have  actually  existed." 

In  the  course  of  time  it  became  more  and  more  apparent  that 
R.  was  a  degenerate  chronic  alcoholic,  who  simulated  paranoia  in 
order  to  evade  regular  work  and  that  he  might  lead  a  comfortable 
life  in  the  institution.  He  was  then  discharged  from  the  asylum 
and  soon  afterward  emigrated  to  America. 


PRACTICAL  EXAMPLES  395 

Here  he  worked  assiduously  for  a  time,  but  he  frequently 
changed  his  occupation.  He  again  began  to  drink,  became  needy, 
cheated  landlords,  swindled  other  persons  and  was  sent  to  the 
penitentiary  repeatedly  in  New  York  and  other  cities.  He  would 
work  only  when  in  the  most  dire  need  and  when  it  became  im- 
perative for  him  to  obtain  money  to  satisfy  his  alcoholic  wants. 
Ultimately  he  was  employed  as  a  janitor  in  a  country  house,  the 
proprietor  of  which  lived  in  New  York.  In  the  absence  of  the 
latter  and  his  family,  R.  broke  into  certain  living  rooms  to  steal 
jewelry  and  other  articles  of  value,  but  was  arrested  before  he 
could  dispose  of  them. 

Physical  examination  of  R.  revealed:  A  man  of  medium 
height,  well  nourished,  and  of  comparatively  healthy  appearance. 
With  the  exception  of  color  blindness  no  physical  signs  of  de- 
generation were  present.  The  corneal  reflexes  were  absent  and 
the  knee  reflexes  were  difficult  to  obtain,  due  to  the  fact  that  R. 
would  not  relax,  and  it  seemed  as  though  he  purposely  avoided 
doing  so.  There  was  a  slight  tremor  of  the  hands,  and  some 
tenderness  of  the  large  nerve  trunks. 

During  the  psychic  examination  R.  was  clear,  collected  and 
oriented.  He  showed  good  conceptual  powers  and  gave  informa- 
tion willingly  and  adroitly.  He  conversed  freely  with  the  people 
about  him,  was  in  good  humor,  told  all  kinds  of  jokes,  played 
cards  with  pleasure,  and  read  a  great  deal.  Only  at  times,  par- 
ticularly at  the  end  of  the  period  of  observation,  was  he  de- 
pressed. Then  he  complained  of  being  tired,  would  not  occupy 
himself  with  anything  and  scolded  about  the  physicians  and  at- 
tendants, and  objected  a  great  deal  to  the  food.  His  appetite 
withal  was  excellent  and  his  sleep  almost  always  good. 

From  the  antecedent  history  of  the  case  and  from  the  clinical 
observation  we  see  that  G.  R.  is  undoubtedly  a  degenerate  de- 
fective. While  his  capabilities  were  good  and  his  accomplish- 
ments in  the  beginning  were  satisfactory,  he  never  succeeded  in 
achieving  anything,  because  his  interest  and  his  assiduity  con- 
sistently waned.  He  began  to  drink,  neglected  his  work  com- 
pletely, was  discharged,  wandered  from  place  to  place  and  finally 
had  recourse  to  swindling  and  deceit.  In  later  life  his  instability 
and  his  inability  to  occupy  himself  permanently  in  any  serious 
capacity  notwithstanding  his  natural  talent  became  even  more 
apparent.     As  is  so  often  the  case  in  persons  of  weak  will,  he 


396    THE  UNSOUND  MIND  AND  THE  LAW 

continued  to  drink,  and  thereby  became  less  capable  of  serious 
work.  And  the  deeper  he  sank  the  more  he  lost  insight  into  the 
fact  that  he  really  never  had  been  able  to  accomplish  anything. 
On  the  contrary,  he  became  presumptuous  and  selfish.  Withal  he 
was  very  sensitive  and  easily  took  offense.  He  had  attacks  of 
violent  anger  when  he  was  censured,  but  in  a  moment  he  was 
likely  to  become  repentant  and  pray  to  be  excused  for  his  un- 
worthy actions. 

It  is  just  this  combination  of  weakness  of  will  and  unbounded 
self-esteem,  associated  with  uncontrolled  emotions  and  submissive 
conduct,  that  constitutes  the  typical  symptom  complex  of  a  de- 
generate psychopathic  personality,  one  that  may  be  designated 
as  unstable.  On  the  physical  side,  as  already  stated,  we  find 
color  blindness,  a  congenital  defect  not  infrequently  found  in 
such  individuals  and  one  that  has  been  classed  among  the  so- 
called  degenerative  signs.  Whether  and  to  what  extent  the  usual 
hereditary  taint  exists  in  this  case  we  cannot  determine,  because 
our  only  history  of  the  man  is  based  on  the  statements  of  R. 
himself,  and  he  naturally  has  an  interest  in  being  declared  insane 
so  he  may  escape  imprisonment. 

In  this  man,  then,  we  find,  during  his  first  detention  in  1893,  a 
peculiar  condition  of  excitement,  in  which  he  tore  the  bed  covers 
and  maintained  he  was  dead  and  saw  black  figures  about  him. 
Following  this  he  evolved  all  kinds  of  nonsensical  ideas  of  a 
persecutory  nature  and  gave  expression  to  delusions  of  grandeur, 
which  even  today  he  repeats  and  to  which  he  attributes  all  his 
criminal  acts  and  particularly  the  theft  of  which  he  is  now  ac- 
cused. At  first  R.  was  supposed  to  be  insane  and,  therefore,  he 
was  not  criminally  prosecuted.  Later  it  was  suspected  he  had 
simulated  insanity.  This  assumption  was  corroborated  while  he 
was  under  my  observation.  Special  evidence  in  support  of  this 
opinion  was  the  fact  that  the  course  of  the  supposed  trouble  in 
R.  was  by  no  means  what  we  are  accustomed  to  see  clinically  in 
chronic  paranoia.  In  this  disease  there  slowly  develops  a  perma- 
nent and  unalterable  delusional  system  which  inevitably  leans  to 
a  decisive  transformation  of  the  person's  entire  view  of  life,  to 
a  transposal  of  the  attitude  which  the  patient  necessarily  main- 
tains toward  persons  and  objects.  It  is  precisely  upon  the  ab- 
sence of  this  last  characteristic  in  R.  that  we  would  lay  special 
emphasis.     Instead  of  suspicion  and  reticence,  we  find  in  him 


PRACTICAL  EXAMPLES  397 

subservient  politeness  and  an  endeavor  to  make  as  favorable  an 
impression  as  possible.  We  see  him  behaving  like  a  normal  per- 
son, his  actions  having  no  relationship  whatsoever  to  the  ideas  of 
persecution  he  claims  to  have.  Notwithstanding  his  claim  that 
he  is  constantly  being  annoyed  he  is  neither  suspicious  nor 
irritable,  but,  on  the  contrary,  is  always  polite,  markedly  friendly 
and  often  even  obsequious.  As  soon  as  he  feels  at  home  in  any 
new  surroundings  his  comportment  becomes  impertinent  and  at 
times  openly  brutal.  But  even  then  he  never  includes  the  person 
whom  he  accused  of  being  inimical  to  him  in  his  delusional  sys- 
tem nor  does  he  delusionally  interpret  that  person 's  comportment 
in  the  way  a  real  paranoiac  would.  While  the  true  paranoiac 
thinks  only  of  the  means  by  which  he  can  escape  his  annoyers 
and  of  the  methods  that  will  aid  him  to  oppose  them  and  hence 
looks  upon  everything  with  suspicion  and  interprets  the  most 
innocent  conduct  as  being  directed  towards  himself,  we  find  R. 
in  a  state  of  complete  confidence  toward  those  surrounding  him. 
He  occupies  himself  remarkably  little  with  his  ideas  of  persecu- 
tion and  the  main  aim  of  his  activities  seems  to  be  his  own  per- 
sonal interest.  In  order  to  attain  his  object  he  seeks  the  favor 
of  the  physician  in  a  most  subservient  manner,  acting  as  a 
paranoiac  would  never  act.  On  the  contrary,  the  attitude  of  the 
paranoiac  will  be  one  of  marked  reticence  and  superiority,  due 
entirely  to  his  exalted  self-consciousness  and  to  the  grandiose 
ideas  which  are  directly  linked  with  his  ideas  of  persecution. 

Upon  the  one  hand  we  find  in  R.  a  total  absence  of  mutual  rela- 
tionship between  the  supposed  delusions  and  upon  the  other,  a 
lack  of  any  transformation  of  personality  in  the  sense  of  the  de- 
lusion. Those  very  points,  therefore,  which  are  essential  to  and 
characteristic  of  true  paranoia  are  wanting. 

In  addition  the  entire  course  of  the  disorder  in  R.  does  not 
correspond  to  what  we  are  accustomed  to  find  in  paranoia.  This 
affection,  we  know,  sets  in  very  slowly  and  insidiously,  progresses 
steadily  and  gradually  gains  more  and  more  ascendancy  until  it 
embraces  everything  with  which  the  patient  is  surrounded.  In 
R.,  however,  we  find  the  disease  beginning  with  a  peculiar  state 
of  excitement,  with  numerous  visions,  illusions  and  the  notion  of 
being  dead,  the  onset  of  ideas  of  persecution  coming  afterward. 
Then,  instead  of  a  slow  development  and  a  steady  increase  of  the 
disease,  we  find  after  a  few  months  that  complete  recovery  has 


398     THE  UNSOUND  MIND  AND  THE  LAW 

taken  place.  This  so-called  mental  disorder,  strange  to  say, 
recurs  whenever  it  seems  opportune  for  R.  to  have  it  do  so. 

It  must,  therefore,  be  plain  that  R.  cannot  be  suffering  from  a 
chronic  paranoia.  But  if  not  from  paranoia,  from  what  psychosis 
does  he  suffer?  By  way  of  answer  to  this  question  we  should 
consider  primarily  the  paranoid  form  of  dementia  prascox.  This 
affection  may  produce  symptoms  similar  to  those  which  have  been 
observed  in  R. ;  and  yet  we  must  admit  that  this  disease  usually 
leads  within  a  few  years  to  a  peculiar  feeble-minded  state.  This 
should  certainly  be  present  in  R.  if  he  had  been  suffering  from 
dementia  prascox  paranoidea  for  the  last  twenty  years. 

There  still  remains  for  our  consideration  one  other  form  of 
mental  disorder  which  runs  its  course  much  as  did  the  disease 
which  R.  appears  to  have.  This  is  known  as  hallucinosis  of  alco- 
holics. That  R.  was  a  heavy  drinker  is  clearly  shown  by  the 
official  records  that  alcoholic  addiction  had  existed  for  a  long 
time  prior  to  the  onset  of  the  mental  disorder.  While  a  sudden 
beginning  is  nothing  unusual  in  this  disease,  yet  the  state  of  ex- 
citement and  the  notion  of  being  dead  that  existed  do  not  at  all  fit 
into  the  picture  of  this  affection.  True,  the  visual  deceptions 
which  the  patient  claims  to  have  had  may  occur  in  this  form  of 
alcoholic  mental  disorder.  Of  much  more  weight,  however, 
is  the  fact  that  the  characteristic  symptoms  of  alcoholic  halluci- 
nosis, more  especially  the  numerous  vivid  auditory  deceptions 
that  bear  a  persecutory  aspect  and  often  cause  the  patient  to  at- 
tempt self-destruction  on  account  of  fear,  are  absent.  An  alco- 
holic hallucinosis,  therefore,  must  also  be  excluded. 

Now,  if  we  gather  all  the  facts  and  consider  particularly  that 
the  manifestations  of  disease  become  apparent  in  R.  only  when  it 
is  to  his  advantage  to  have  them  do  so,  but  disappear  as  soon  as 
they  are  of  no  further  service  to  him,  we  cannot  avoid  the  con- 
clusions that  R.  has  acted  in  accordance  with  a  well-considered 
plan  and  that  all  his  so-called  notions  of  persecution  are  not  de- 
pendent upon  any  mental  disorder,  but  are  simulated.  R.  has 
been  able  to  support  himself  only  in  a  most  precarious  way,  often 
coming  into  conflict  with  the  criminal  law  and  preferring  a  so- 
journ in  an  asylum  to  the  prison  cell.  This  probably  explains 
everything. 

My  opinion,  therefore,  is  that  R.,  although  a  degenerate  and 
inferior  individual,  has  at  no  time  suffered,  nor  does  he  at  pres- 


PRACTICAL  EXAMPLES  399 

ent  suffer,  from  any  pathological  disturbance  of  mental  activity 
in  consequence  of  which  his  voluntary  determination  has  been  ex- 
cluded. "Whether  the  existence  of  mitigated  responsibility  is  to 
be  assumed  must  remain  a  matter  for  the  court  to  decide. 

(Signed)  Dr.  N.  N. 

5.   Commitment   to   an   Asylum   on   Account  of   Being  a 
Public  Menace 

The  undersigned  was  requested  on  March  18th,  19 — ,  by  C.  H., 
a  dealer  of  books  in  the  City  of  New  York,  to  examine  into  the 
mental  condition  of  his  son,  F.  H.,  22  years  of  age,  a  student  at 
Columbia  University,  who  for  some  time  had  been  acting  in  a 
peculiar  manner  and  who  had  planned  to  kill  his  entire  family. 
After  a  prolonged  examination  and  observation  I  have  been  able 
to  determine  that  F.  H.  suffers  from  delusions  of  persecution 
which  abolish  his  free  determination.  In  consideration  of  the 
existing  state  of  affairs  and  in  view  of  all  psychiatric  experience, 
we  must  assume  that  F.  H.  will  carry  out  his  plan  if  he  gets  the 
opportunity.  It  would  be  most  dangerous  to  leave  an  irre- 
sponsible person  in  freedom  so  long  as  he  is  dominated  by  delu- 
sions of  persecution  which  in  any  unguarded  moment  would  lead 
him  to  commit  an  act  of  violence.  It  is  my  opinion  that  as  F.  H. 
is  suffering  from  so  dangerous  a  psychosis  he  should,  for  his  own 
protection  as  well  as  that  of  those  surrounding  him,  be  com- 
mitted to  an  institution. 

In  support  of  this  opinion  I  will  first  adduce  from  the  patient 's 
family  history  such  facts  as  I  have  been  able  to  ascertain.  The 
father,  C.  H.,  is  a  highly  cultured  and  talented  man,  who,  since 
the  death  of  his  wife  three  years  ago,  has  been  suffering  from  de- 
pression and  has  at  various  times  given  utterance  to  suicidal 
ideas.  A  brother  of  the  father  has  attempted  suicide.  A  distant 
relative  was  insane.  Other  members  of  the  family  are  said  to 
have  suffered  from  various  nervous  disorders.  F.  H.  himself 
was  the  seventh  of  thirteen  children,  three  of  whom  died  in  in- 
fancy. He  developed  apparently  normally.  His  teachers  char- 
acterize him  as  assiduous,  upright  and  conscientious.  Under  the 
training  of  his  very  religious  mother,  the  boy  developed  intro- 
spective traits  which  tended  to  make  him  look  upon  slight  fail- 


400    THE  UNSOUND  MIND  AND  THE  LAW 

ings  or  harmless  excursions  as  a  great  sin.  He  was  very  musical 
and  a  lover  of  all  kinds  of  sports. 

A  remarkable  trait  from  the  very  beginning  was  his  extreme 
secludedness.  At  all  times  he  seems  to  be  depressed.  He  never 
jokes  or  laughs  with  his  comrades  and  has  no  close  friends.  Dur- 
ing the  last  years  in  school,  according  to  his  own  statements,  he 
masturbated  continually.  Similarly,  during  his  period  in  col- 
lege he  was  more  or  less  "shut  in"  and  made  a  melancholic  im- 
pression. One  of  the  professors  who  had  visited  him  in  his  home 
had  remarked  upon  the  touching  tenderness  the  youth  always 
showed  toward  his  father.  This  professor  looked  upon  F.  H.  as 
an  extraordinarily  good  and  dependable  man,  but  he  considered 
him  peculiar,  slow  in  thought,  though  clear  and  logical,  severe  in 
his  opinion  of  himself,  but  lenient  toward  the  weaknesses  of 
people. 

About  two  years  ago,  contrary  to  his  former  religious  manner 
of  thought,  he  wrote  letters  of  a  most  depressive  nature  to  his 
mother's  sister,  full  of  self -accusations,  in  which  he  emphasized 
that  his  entire  life  was  directly  antagonistic  to  God  and  religion. 
He  was  embittered  and  knew  he  could  never  be  otherwise.  He 
was  deeply  unhappy  because  his  life  seemed  to  be  a  failure.  The 
slightest  mental  work  proved  an  exertion.  He  maintained  that 
the  satisfaction  of  his  excessive  sensual  ideas  (onanism)  had  ex- 
hausted him  bodily  and  mentally,  so  that  it  was  perfectly  imma- 
terial to  him  whether  he  was  considered  a  good  or  a  bad  person. 
It  was  his  desire  to  become  even  more  depraved.  The  thought  of 
God  did  not  in  any  way  influence  him.  He  prayed  to  the  devil 
each  day,  begging  him  to  suppress  every  noble  thought  he  might 
have  until  whatever  the  devil  had  ordained  should  have  been  ac- 
complished. According  to  F.  H.'s  own  assertions,  his  anger 
against  God  had  constantly  increased.  In  order  to  annoy  God 
he  had  masturbated  excessively,  and  then  the  thought  came  to 
him  to  cause  God  still  more  sorrow  by  some  horrible  deed.  It 
was  his  intention  in  committing  this  deed  to  bring  death  also  to 
himself.  Knowing  that  his  father  was  greatly  worried  about  the 
other  children  and  had  had  suicidal  ideas,  the  patient  became 
more  and  more  convinced  that  the  death  of  his  father  would  be 
nothing  terrible,  but,  on  the  contrary,  would  signify  his  liberation 
from  all  suffering.  Inasmuch,  however,  as  the  death  of  his  father 
would  cause  his  brothers  and  sisters  great  sorrow  and  would 


PRACTICAL  EXAMPLES  401 

deprive  them  of  their  protector,  F.  H.  considered  it  proper  not 
to  allow  the  father  to  die  alone.  In  the  beginning  the  patient 
claimed  to  have  been  conscience-stricken;  but  gradually  his 
scruples  were  overcome  by  the  thought  that  his  father  and  his 
brothers  and  sisters,  through  death,  would  find  entrance  into 
heaven.  It  was  his  sole  desire  to  kill  all  of  them  and  then  to  com- 
mit suicide  so  he  might  receive  just  punishment  by  being  rele- 
gated to  Hell. 

Another  noteworthy  feature  was  the  fact  that  he  repeatedly 
interrupted  his  studies  and  undertook  travels  without  apparent 
motive  or  object.  One  of  his  class  acquaintances  maintained  the 
patient  had  made  upon  him  an  unsteady  restless  impression, 
acting  as  though  he  had  a  bad  conscience.  That  he  had  actually 
determined  upon  the  death  of  the  entire  family  is  shown  by  the 
excitement  which  overtook  him  when  a  loaded  revolver  which 
he  had  secretly  purchased  and  concealed  was  taken  from  him. 

F.  H.  is  a  medium-sized,  ill-nourished  man;  he  suffers  from 
pronounced  sleeplessness  and  frequently  refuses  to  take  food. 
The  measurements  of  the  skull  and  an  examination  of  the  inter- 
nal organs  reveal  no  abnormality.  The  patient  maintains  he 
has  never  taken  any  alcohol  and  that  he  has  never  had  any 
sexual  connection.  He  claims  that  a  year  ago  he  gave  up  the 
masturbation  he  formerly  practised.  No  defects  of  sensory 
organs  are  demonstrable.  The  pupils  react  promptly  to  light 
and  accommodation,  but  the  patellar  reflexes  are  sluggish.  The 
patient  is  well-oriented  in  regard  to  time  and  place.  His  mem- 
ory for  recent  events  is  markedly  restricted,  inasmuch  as  names, 
figures  and  objects  to  which  his  attention  has  been  called  are 
usually  forgotten  by  him  within  a  half  hour.  On  the  other  hand 
he  is  able  to  recall  occurrences  from  his  previous  life  with  a 
marked  degree  of  accuracy.  Intelligence  tests  enable  us  to 
recognize  the  presence  of  a  mild  degree  of  mental  enfeeblement. 
Whereas  until  five  years  ago  he  was  looked  upon  as  a  model 
pupil,  he  has  more  recently  remained  far  behind  his  associates 
in  his  college  work.  Most  noticeable  is  his  marked  emotional 
indifference,  his  lack  of  the  natural  manifestations  of  pleasure 
or  displeasure.  The  ideas  of  persecution  from  which  F.  H.  suf- 
fers seem  to  be  dependent  upon  auditory  hallucinations.  From 
things  he  believes  to  have  heard,  he  has  learned  that  the  entire 
world  is  inimical  to  him  and  to  his  family.     He  sees  no  other 


402    THE  UNSOUND  MIND  AND  THE  LAW 

means  of  escape  from  the  destruction  that  his  enemies  have  pre- 
pared for  him  than  flight  into  another  world.  Nor  is  there  any- 
other  means  of  salvation  for  his  family,  and  for  this  reason  he 
must  take  them  with  him.  At  times  he  becomes  conscience- 
stricken,  and  in  this  state  he  unfolds  his  innermost  thoughts. 
Then  he  says  he  has  no  more  use  for  God  because  God  has  not 
protected  him  against  the  persecutions  and  the  injustice  to  which 
he  has  been  subjected. 

During  the  examination  it  was  often  difficult  to  get  the  patient 
to  express  himself  at  all.  He  anxiously  concealed  his  thoughts. 
Sometimes  he  seems  to  be  listening  to  inaudible  voices ;  at  other 
times  he  seems  to  have  the  need  of  expressing  himself  freely,  and 
then  he  acknowledges  that  he  received  the  command  to  murder 
the  entire  family. 

Summing  up,  we  find  the  picture  of  an  hereditarily  tainted 
young  man,  who  is  evidently  suffering  from  the  paranoid  form 
of  dementia  prgecox.  F.  H.  has  always  been  peculiar.  No  one 
was  astonished  when  he  did  extraordinary  things.  First,  the 
depressed  letters  that  he  wrote  to  his  aunt  attracted  attention, 
then  followed  the  foolish  self-accusations  and  the  break  with 
religion.  F.  H.  believed  God  had  deserted  him  and  turned  him 
over  to  his  enemies.  It  was  his  desire  to  grieve  God  by  some 
dreadful  deed.  Moreover,  it  was  his  idea  that  by  killing  his 
father  and  his  sisters  he  would  free  them  from  further  troubles 
and  sorrow.  He  asserts  that  the  devil  dominates  him  and  con- 
stantly urges  him  to  take  himself  and  his  family  out  of  the 
world.  It  is  perfectly  clear  that  a  person  acting  from  such 
motives  will  be  most  reticent  concerning  his  proposed  act.  His 
plans,  however,  are  unfolded  in  one  of  his  letters,  in  which  he 
writes  that  his  only  prayer  is  that  the  devil  may  suppress  every 
good  trait  he  may  have  until  he  has  carried  out  what  he  must  do. 
Occasionally  his  conscience  worries  him,  and  he  then  lays  bare 
his  inner  self.  At  such  times  he  has  repeatedly  said  he  must 
kill  the  entire  family  in  order  to  save  them  from  misfortune. 
The  excessive  masturbation,  by  means  of  which  the  patient, 
according  to  his  own  statement,  would  still  further  insult  God, 
no  doubt  has  produced  a  state  of  marked  exhaustion.  Neverthe- 
less the  onanism  must  be  looked  upon  not  as  a  cause  but  as  a 
result  of  the  disease  from  which  he  is  suffering.  The  question, 
then,  is  whether  a  psychopathically  tainted  individual  who  is 


PRACTICAL  EXAMPLES  403 

run  down  from  constant  masturbation,  who  is  mentally  and 
emotionally  dull,  who  suffers  from  auditory  hallucinations  and 
delusions,  but  who  up  to  the  present  time  has  not  committed  any 
punishable  act,  may  be  considered  a  public  menace,  whether,  in 
other  words,  the  patient,  if  allowed  his  liberty,  would  carry  out 
the  purpose  he  had  expressed.  This  question  must  be  answered 
affirmatively. 

In  general  we  must  regard  as  a  public  menace  all  individuals 
whose  psychic  irregularities  would  lead  us  with  reasonable  cer- 
tainty to  expect  that  they  could  live  unguarded  without  coming 
into  conflict  with  the  criminal  law  or  without  doing  injury  to 
themselves.  Patients  suffering  from  mental  disease  are  a  public 
menace,  if  for  no  other  reason  because  they  are  deprived  of  their 
power  of  voluntary  determination,  and  through  false  notions  or 
imperative  impulses  are  urged  to  commit  detrimental  deeds.  It 
is  entirely  erroneous  to  believe  that  the  feeble-minded  are  always 
harmless.  It  has  often  been  shown  that  very  slight  provocation 
may  be  the  cause  for  a  weak-minded  individual  to  commit  a 
dangerous  crime  such  as  incendiarism,  onslaught  upon  persons, 
or  even  murder.  The  feeble-minded  of  light  and  of  severe 
degree  and  the  majority  of  mental  defectives  should  be  judged 
not  according  to  their  mental  state  but  also,  just  as  ordinary 
criminals,  by  the  motives  that  govern  them.  "When  a  feeble- 
minded person  is  depressed  and  suffers  from  delusions,  it  is  quite 
evident  that  under  the  sway  of  hallucinatory  influence  he  may 
conceive  and  carry  out  the  idea  of  committing  some  pernicious 
act.  Of  course,  it  can  never  be  proven  with  certainty  that  every 
insane  person  who  is  not  committed  to  an  institution  will  commit 
a  criminal  act.  But  it  would  be  an  exceedingly  dangerous  pro- 
cedure to  defer  a  commitment  until  some  calamity  had  taken 
place. 

Very  often  individuals  who  are  depressed  will  commit  both 
murder  and  suicide.  Their  first  thought  is  of  their  own  death ; 
then  they  think  of  the  relatives  who  love  them  and  who  they 
believe  could  not  live  without  them,  and  they  determine  to  take 
them  along.  Every  psychiatrist  knows  that  melancholiacs  are 
dangerous  because  they  carefully  consider  and  plan  their  acts. 
Planning  of  this  sort  is  shown  in  P.  H.  because  of  his  secret 
purchase  and  concealment  of  a  revolver.  Most  dangerous  of  all 
are  those  patients  who  hear  voices  which  command  them  to  com- 


404    THE  UNSOUND  MIND  AND  THE  LAW 

mit  a  certain  deed.  In  them  the  explosion  may  come  entirely 
without  warning.  More  frequent  are  the  instances  in  which  the 
voices  do  not  command,  but  tell  the  patient  to  protect  himself 
against  his  enemies.  When  this  happens  the  patients  as  a  rule 
communicate  their  delusional  ideas  to  their  relatives,  as  was 
done  by  F.  H.  When  the  ideas  of  persecution  are  extremely 
intense  or  are  accompanied  by  sense  deceptions  they  may  readily 
lead  to  an  explosion.  In  many  instances,  the  patients,  before 
taking  extreme  measures,  will  try  everything  else  in  order  to 
rid  themselves  of  their  supposed  prosecutors  or  to  protect  them- 
selves against  them.  Very  often  we  will  find  them  changing 
their  residences,  and  probably  the  senseless  travels  of  F.  H.  had 
been  undertaken  for  this  purpose,  the  patient  hoping  thus  to 
escape  the  persons  and  the  annoying  voices  that  followed  him. 
Where  the  patients  are  unable  to  rid  themselves  of  their  perse- 
cutors in  a  safe  manner  they  take  recourse  to  an  attempt  at 
suicide  and  to  threats  against  people  about  them.  This  not 
availing,  they  take  the  most  extreme  measures.  This  is  what  we 
would  expect  to  happen  in  the  case  of  F.  H. 

In  endeavoring  to  determine  the  mental  condition  and  respon- 
sibility of  a  person  who  as  yet  has  committed  no  crime,  the 
expert  can  only  say  what  will  probably  take  place.  I  cannot 
unreservedly  maintain  that  F.  H.,  if  he  is  not  committed  to  an 
institution,  will  carry  out  the  family  murder  he  has  planned, 
but  I  must  emphasize  the  fact  that  in  similar  cases,  in  which  no 
attention  has  been  paid  to  the  delusions  and  the  threats  of  the 
patients,  acts  of  great  violence  have  been  committed.  It  is  not 
reasonable  to  assume  that  the  actions  of  F.  H.  will  be  different 
from  those  of  other  insane  individuals  who  suffer  from  depres- 
sion and  who,  under  the  influence  of  ideas  of  persecution,  com- 
mit murder  or  suicide  at  the  first  opportunity. 

It  is  my  opinion  that  F.  H.  is  insane  and  is  deprived  of  his 
free  determination,  and  that  the  nature  of  his  psychosis  would 
lead  us  to  expect  an  outbreak  of  violence  at  any  time.  There- 
fore, in  order  that  the  patient  and  his  surroundings  may  be 
protected  from  injury,  I  advise  that  he  be  committed  to  an 
institution  until  his  delusions  have  entirely  passed  away. 

(Signed)   Dr.  N.  N. 


LITERATURE 


LITERATURE 

Abderhalden  (Emil),  ' '  Abwehrf ermente  des  tierischen  Organis- 

mus   gegen   koerper-,    blutplasma-,   und   zellfremde    Stoffe," 

Berlin,  1913. 
Abderhalden   (Emil),  ' ' Serologische  Diagnostik  von  Organver- 

aenderungen, "  Deutsche  med.  Wochenschrift,  1913,  No.  39. 
Aschaffenburg    (Gustav),    "Handbuch  der   gerichtlichen  Psy- 
chiatric," 1911. 
Bateson    (William),   "A  Presidential  Address   on  Heredity," 

The  Lcmcet,  Aug.  15,  1914. 
Berillon    (Edgar),  " L 'hypnotisme  experimentale.     La  dualite 

cerebrale,  etc.,"  Paris,  1884. 
Berze  (Josef),  "Gehoeren  gemeingefaehrliche  Minderwertige  in 

die  Irrenanstalt  ? "  Wiener  mediz.  Wochenschrift,  No.  26,  p. 

1251,  1901. 
Bianchi  (Leonard),  "A  Text  Book  of  Psychiatry,"  Translation 

from  the  Italian,  New  York,  1906. 
Birnbaum  (Karl),  "Die  psychopathischen  Verbrecher.     Hand- 

buch  fur  Aerzte  Juristen  und  Straf anstaltsbeamte, "  Berlin, 

1914. 
Bischoff  (Ernst),  "Lehrbuch  der  gerichtlichen  Psychiatrie  fur 

Mediziner  und  Juristen,"  Berlin,  1912. 
Brouardel    (Paul),  "Accusation  du  viol  accompli  pendant  le 

sommeil  hypnotique,  etc.,"  Anna.les  d'hygiene  et  de  medecine 

legale,  1879,  3  Serie,  Vol.  1,  p.  39. 
Bumke   (0.),  ' '  Gerichtliehe  Psychiatrie,   5  Abteil.     Handbuch 

der  Psychiatrie"  (Aschaffenburg),  Leipzig-Wien,  1912. 
Charpignon    (Jules),  "Physiologie  du  magnetisme,"  1848,  p. 

297  et  seq. 
Charpignon   (Jules),  "Rapports  du  magnetisme  avec  la  juris- 
prudence et  la  medecine  legale,"  Paris,  1860,  p.  48 
Cramer  (A.),  "  Grenzzustaende, "  Zeitsch.  f.  Aerztl.  Fortbildg., 

No.  6,  p.  167,  1907. 
Czynski,  "Der  Prozess,"  Tatbestand  und  Gutachten,  etc.,  vor 

dem  oberbayr.     Schwurgericht  zu  Miinchen,  Stuttgart,  1895. 
Delbriick  (Anton),  "Die  pathologische  Luge,"  Stuttgart,  1891. 

407 


408    THE  UNSOUND  MIND  AND  THE  LAW 

Dercum  (Francis  X.),  "The  Story  of  Dementia  Praecox,"  New 
York  Med.  Journal,  1916,  Vol.  II,  p.  290. 

Du  Potet  (J.),  "Traite  complet  de  magnetisme, "  1821,  p.  613  et 
seq. 

Fauser  (A.),  "Die  Serologic  in  der  Psychiatrie, "  Miinchener 
med.  Wochenschrift,  No.  36,  1913;  No.  3,  1914. 

Fauser  (A.),  "Ueber  die  Bedeutung  der  neueren  Entwickelung 
der  Psychiatrie  fur  die  gerichtliche  Medizin,"  Juristisch- 
psychiat.  Grenzfragen,  Bd.  II,  No.  1  and  2,  1913. 

Forel  (Aug.),  "Der  Hypnotismus, "  Stuttgart,  1911. 

Frese,  "Der  Querulant  und  seine  Entmuendigung, ' '  Juristisch- 
psychiat.  Grenzfragen,  Bd.  VI,  No.  8. 

Ganser,  "Ueber  einen  eigenartigen  hysterischen  Daemmerungs- 
zustand,"  Arch.  f.  Psych.,  Bd.  30,  No.  2. 

Grasset  (J.),  "Demi-fous  et  demi-responsables, "  1907.  Trans- 
lated by  Jelliffe  (S.  E.),  "The  Semi-Insane  and  the  Semi-Re- 
sponsible. ' ' 

Gudden  (Hans),  " Schlaf trunkenheit, "  Arch.  f.  Psychiat.,  Bd. 
40,  p.  989. 

Haeser,  "Geschichte  der  Medizin,"  Jena,  1882. 

Healey  (William),  "The  Individual  Delinquent,"  Chicago, 
1915. 

Hegar  (A.),  "Der  Geschlechtstrieb, "  Stuttgart,  1894. 

Heilbronner,  "  Selbstanklage  und  pathologische  Gestaendnisse, " 
Muench.  med.  Wochenschrift,  1914.    No.  7. 

Hoche,  "Zur  Frage  der  forensichen  Beurtheilung  sexueller  Ver- 
gehen,"  Neurol.  Centralblatt ,  1896,  No.  2. 

Hoche  (A.),  "Handbuch  der  aerztlichen  Sachverstaendigen- 
tbaetigkeiten, "  Berlin,  1905. 

Hoche  (A.),  "Handbuch  der  gerichtlichen  Psychiatrie,"  Ber- 
lin, 1909.    2d  Ed. 

Horner  (A.),  "Der  Blutdruck  des  Menschen,"  Wien,  1913. 

Huebner  (A.  H.),  "Lehrbuch  der  forensichen  Psychiatrie," 
Bonn,  1914. 

Jacoby  (George  W.),  "Einiges  ueber  den  modernen  Hypnotis- 
mus," New  York,  1891. 

Jacoby  (George  W.),  "The  Commitment  of  the  Insane  and  the 
Insanity  Law. "    N.Y.  Med.  Journal,  Nov.,  1896. 

Jacoby  (George  W.),  "Psychiatric  Expert  Evidence  in  Criminal 
Proceedings,"  N.  Y.  Medical  Journal,  March  7,  1908. 


LITERATURE  409 

Jacoby   (George  W.),  ''Suggestion  and  Psychotherapy,"  New 

York,  1912. 
Jacoby   (George  W.),  "Child  Training  as  an  Exact  Science," 

New  York  &  London,  1914. 
Jacoby  (George  ~W.),  "Exact  and  Inexact  Methods  in  Neurol- 
ogy and  Psychiatry."    Presidential  Address,  Journal  of  Nerv- 
ous and  Mental  Diseases,  1915,  p.  660. 
Jacoby  (George  W.),  "The  Curatelle  and  Modern  Psychiatry," 

N.  Y.  Med.  Journal,  June,  1916. 
Kiernan  (J.  G.),  "Insane  Confessions,"  etc.,  The  Alienist  and 

Neurologist,  Yol.  8,  No.  4,  1897. 
Koch  (J.  L.  A.),  "Die  psychopathischen  Minderwerthigkeiten, " 

Ravensberg,  1891. 
Kornfeld  (Herman),  " Geisteskrankheit  in  amerikanischer,  en- 

glischer  und  deutscher  Rechtssprechung, "  Archiv  f.   Erim- 

inalanthropologie,  Bd.  3,  p.  197,  1900. 
Kornfeld  (Herman),  "Die  Entmuendigung  Geistesgestoerter, " 

1901. 
Kornfeld   (S.),  "Geschichte  der  Psychiatrie"  in  Puschmann's 

"Handbuch  der  Geschichte  der  Medizin,"  Vol.  3,  Jena,  1905, 

pp.  601-728. 
Krafft-Ebing    (R.   von),    " Psychopathia    Sexualis,"    Stuttgart, 

1894. 
Krafft-Ebing   (R.  von),  "Der  Contraersexuale  vor  dem  Straf- 

richter,"  Leipzig  und  Wien,  1895. 
Krafft-Ebing    (R.   von),    "Die   Zweifelhaften    Geisteszustaende 

vor  dem  Civilrichter, "  Stuttgart,  Enke,  1899. 
Krafft-Ebing   (R.  von),  "Lehrbuch  der  gerichtlichten  Psycho - 

pathologie,"  3te.  Auflage,  1900. 
Krafft-Ebing  (R.  von),  "Textbook  of  Insanity,"  Translated  by 

Charles  Gilbert  Chaddock.     Philadelphia,  1905. 
Kratter  (J.),  "Lehrbuch  der  gerichtlichen  Medizin,"  Stuttgart, 

1912. 
Lacassagne  (A.),  "L  Affaire  Gouffe,"  Lyon-Paris,  1891. 
Ladame   (Paul),  "La  nevrose  hypnotique  devant  la  medecine 

legale,   etc.,"   Annates  d'hygiene  publique    et   de   medecine 

legale,  3  Serie,  Vol.  VII,  Jan.,  1882. 
Ladame  (Paul),  " L 'Hypnotism, "  Lyon-Paris,  1888,  p.  35. 
Le  Grand  du  Saulle,  ' '  La  f olie  devant  les  tribunaux, ' '  1864, 


410    THE  UNSOUND  MIND  AND  THE  LAW 

Limaii  (C),  ' '  Zweif elhaf te  Geisteszustaende  vor  Gericht,"  Ber- 
lin, 1869. . 

Longworth  (Stephen  G.),  ''Blood  Pressure  in  Mental  Disor- 
ders," British  Med.  Journal,  1911,  Vol.  I,  p.  1366. 

Marc  (C.  C),  "Die  Geisteskrankheiten  in  ihrer  Beziehung  zur 
Rechtspflege, "  1843-1844,  Translated  from  the  French. 

Meyer  (Ernst),  "Induciertes  Irresein  und  Querulantenwahn, ' ' 
Arch.  f.  Psijch.,  Bd.  34,  p.  181. 

Mittermaier,  "Die  Thaetigkeit  des  medizinischen  in  besondern 
des  psychiatrischen  Sachvertstaendigen  vor  Gerieht,"  Jurist, 
psychiat.  Grenzfragen,  Vol.  5,  part  6. 

Moll  (A.),  "Die  contraere  Sexualempfindung, "  Berlin,  1891. 

Morel  (B.  A.),  "Traite  de  la  medecine  legale  des  alienes,"  1866. 

Mott  (F.  W.),  "The  Causes  of  Insanity,"  The  Lancet,  July  11, 
1914. 

Nonne  (Max.),  "Syphilis  und  Nervensystem, "  Berlin,  1909. 

Padelletti,  "Lehrbuch  der  roemischen  Rechtsgesehiehte, "  1879. 

Penta  (P.),  "Die  Simulation  von  Geisteskrankheit, "  Translated 
into  German  by  Rudolf  Ganter.     "Wurzburg,  1906. 

Plaut  (E.),  "Die  Wassermannsche  Serodiagnostik, "  Jena,  1909. 

Powell  (Richard  Douglass),  "Advances  in  Knowledge  regard- 
ing Circulation  and  Attributes  of  the  Blood  since  Harvey's 
Time,"  The  Lancet,  October  31,  1914. 

Preyer  (W.),  "Ein  merkwiirdiger  Fall  von  Fascination,"  Stutt- 
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Prichard,  "Treatise  on  Insanity,"  London,  1835. 

Prince  (Morton),  "Sexual  Perversion  or  Vice?"  Journal  of 
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Raecke,  "Zur  psychiatrischen  Beurtheilung  sexueller  Delikte," 
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Raecke,  "Grundriss  der  psychiatrischen  Diagnostik,"  Berlin, 
1913. 

Raffalowich  (Marc-Andre),  "Uranisme  et  unisexualite, "  Lyons- 
Paris,  1896. 

Reil  (J.  C),  "Rhapsodien  ueber  die  Anwendung  der  psychi- 
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Reil  (J.  C),  "Kleine  Schriften,"  Halle,  1817. 

Scholz  (L.),  "Anomale  Kinder,"  Berlin,  1912. 

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tung  der  Suggestion,"  Arch.  f.  Kriminal  Anthropologic,  1900. 


LITERATURE  411 

Seiffer,  "Ueber  Exhibitionismus,"  Arch.  f.  Psych.,  Bd.  31,  parts 

1  and  2. 
Siefert  (D.),  " Schlaftrunkenheit, "  Arch.  f.  Neurol,  u.  Psych., 

Vol.  XIII,  p.  161 ;  XIV,  p.  189. 
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Vol.  12,  p.  1. 
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dem  "Handbuch  der  ger.  Med."  von  Schmidtman,   Berlin, 

Aug.  Hirschwald. 
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1894. 
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Psychopathologie    auf    naturwissensehaftlicher    Grandlage, " 

Leipzig,  Johann  Ambr.  Bartb,  1904. 
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Vol.  59,  July,  p.  478. 
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Exper.  Biol,  and  Med.,  1914,  XI,  p.  136. 
Tardieu,  "Etude  medico-legale  sur  la  folie,"  1872. 
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15,  1899. 
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schrift,  1914,  No.  6. 
Wedmeyer  und  Jahrmaerker,  "Die  Praxis  der  Entmundigung 

wegen  Geisteskrankheit  und  Geistesschwache, "  1908. 
Werner,  "Geistig  Minderwertige  oder  Geisteskranke, "  Berlin, 

Fischer's  Med.  Buehhandlung,  1906. 
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III.    Venetiis,  1751. 
Ziehen   (Th.),  "Die  Erkennung  der  psychopathischen  Konsti- 

tutionen  und  die  oeffentliche   Fiirsorge   fiir  psychopathisch 

veranlagte  Kinder,"  Berlin,  1912. 
Ziehen  (Th.),  "Zur  Lehre  von  den  psychopathischen  Konstitu- 

tionen,"  Charite  Annalen,  Vols.  29-30,  1911. 
Zingerle,   "Ueber  transitorische    Geistesstoerungen  und   deren 

forensiche  Bedeutung,"  Jurist,  psychiat.  Grenzfragen,  VIII, 

7. 


INDEX 


INDEX 


Abasia,  256. 

Abderhalden,  51,  88,  89,  90,  92,  93,  94, 

126,    184. 
Absinthe,    304. 

Accusations,  false  self-,     101,     172. 
Achromatopsia,    254. 
Acute    hallucinatory    confusion,    213, 

214. 

differential    diagnosis,    215. 

Acute  hallucinatory  insanity,   233. 
Adaption,  power  of,  65. 
Adventurers,    259. 

—  international,    172. 

Affects,   influence  of  strong,   253. 

—  the,  in  paranoia,  221. 
Agarophobia,    262. 
Agitated    melancholia,    234. 
Aidomania,  333. 
Akromegaly,   89. 
Alchemy,    32. 

Alcohol,  intolerance  to,  289. 

—  intoxication,    190. 
Alcoholic   delirium,    135,    293. 

amnesia    after,    168. 

memory   in,    165. 

objective  signs  of,   115. 

Alcoholic ;    diminished    responsibility 
in   an,    47. 

—  epilepsy   in   an,   290. 

—  facial   expression   of   the,    111. 
Alcoholic   insanity,    219. 

ideas  of  persecution  in,  153. 

■ —  intoxication,  216. 

Alcoholics,    false    accusations    of,    172. 

— ■  crimes   of,   289. 

Alcoholism  and  crime,   13. 

Alcoholism,    chronic,    297f,     302. 

—  periodic,    244. 

■ —  responsibility    in,    12. 
Algolagnia,    335,    342. 
Amnesia,   166,  289. 

—  anterograde,    296. 

—  in   epilepsy,    271. 

—  retrograde,   171,  256,  257. 
Anaesthesia,     of     mucous     membranes, 

254. 

—  sexualis,   334. 

Anamnesis,    100,    102,    103,    138. 

—  diagnosis  from  the,   108. 
Anatomic,    physiologic    relations,    120. 
Ancestral   tree,    103. 

Androgynia,   351. 

Anhedonias,   331. 

Animal    magnetism,    310. 

Aphasia,   129,   130,    280. 

Apoplectic    attacks,    280. 

Appearance  and   care  of  the  body  in 

insanity,  115,  116. 
Archives,    anamnestic,    104. 

—  state,     106. 
Aristotle,  31. 

Aristotle's  belief  in  the  supernatural, 

27. 
Arnold,   36. 
Arnold,  Thomas,  41. 


Arteriosclerosis,    125. 
Associated    movements,    129. 
Association  breadth,  177,  179. 

—  laws,    176. 
Association,   powers  of,  230. 

—  test,   176,   177,   178. 
Astasia,    256. 
Astrology,   31,   32. 

Asylums    for    the    insane,    private,    in 

England,   41. 
Attention    to    self,    253. 
Attentiveness,   augmented,   229. 
Auditory       hallucinations,       objective 

signs   of,    114. 
Aura,    268. 
Authors  and   composers  as  periodists, 

244. 
Autopsies,  79. 
Auto-suggestion,    250,    314. 
Average    values,    54. 
Azam,   312. 

Bacon,  Francis,  inductive  investiga- 
tions   of,    33. 

Bacon,  Roger,  30. 

Bedlam,   41. 

Bell,   35,   42. 

Bernheim,    312,    313,    318,    326. 

Blchat,  35,  42. 

Binet,  338. 

Binet-Simon  test,     178.     179. 

Blind  and  deaf,  tendency  of  the,  to 
develop  abnormally,  124. 

Blind,  hallucinations  of  sight  in  the, 
142. 

Blood,  Abderhalden's  method  of  ex- 
amination of  the,  51. 

—  examination,   50,   90,   125,   126. 

—  expectoration  of,  253. 
Blood  pressure,  the,  119. 
Borderline  individuals,   81. 

—  states,  11,  98,  99. 

not  to   be  judged   by  individual 

symptoms,    55. 

■ transitory    or    permanent,    15. 

Braid,  312. 

Brain,  focal  disease  of  the,  190. 

—  resistibility  of,  77. 
— .syphilis,   190. 

Brains   of   the   insane,   changes  in,   8. 

Broca,    312. 

Brown,    34. 

Bruno,   Giordano,   30. 

Business  capacity,  80. 

Ca?sar,  medical  and  psychiatric  knowl- 
edge at  the  time  of,   35. 

"Carolina,"   the,  36. 

Casper,    Liman,    333. 

Catalepsy,  312. 

Causation  of  disease,  65. 

Causes,  extrinsic  and  psychopathic 
taint,  78. 

Celsus,   23. 

Cephalic    index,    122. 


415 


416 


INDEX 


Character  alteration,  277. 

in  paranoia,  222. 

Charcot,  255,  312,  313. 

Chiarugi.    42. 

Child    labor    laws,    74. 

Children,  city  and  country  bred,  74. 

■ —  violation   of,  335. 

Chloral,    304. 

Chloroform.    304. 

Chorea,   274f. 

—  differential  diagnosis,  275. 

■ —  prognosis    of    mental    disorders    in, 

275. 
Circular   insanity,    243. 
Classification,  according  to  similarities 

and    dissimilarities,    46. 

—  everv    scheme    more   or    less   incom- 

plete, 46. 

—  of  mental  disorders,  56-85. 

—  of     the     psychoses    and     neuropsy- 

choses,   45. 

—  system    of,    47. 

Climacteric,    disorders    of    the,    92. 
Cocainism,   219,   303. 
Colonies,  agricultural,  44. 
Commitment,  5. 

—  to  an  asylum  on  account  of  being  a 

public   menace,    399f. 

Competency  in  commercial  matters,  5. 

Conditions  of  life :  favorable  or  un- 
favorable,   75. 

Conduct,    in   senile   dementia,    279. 

Confabulations,  168,  169,  170,  171, 
193,   226,   252,   291,   296. 

—  as  a  trait  of  character,    171. 

—  as  hallucinations  of  memory,   171. 

—  as   illusions   of   memory,    171. 

—  as   purposeful   falsehoods,    172. 

—  of    the    insane    and    criminal    laws, 

172. 
Confessions,  self,  100. 
Confidence   men,    125. 
Conflict  and  struggle,  62. 
Confusion,  133,   134. 

—  transitory   mental,  364. 
Conolly,    43. 

Consciousness,  double,   257. 
Constitutional    inferiority,    260,    263f. 

forensic  aspects,  266. 

Contractures,  256. 

Convulsions,   254. 
Credibility,  determination  of,  374. 
Cretinism,    8,    89,    92. 
Crighton,    Alexander,    41. 
Crimes  of  alcoholics,   289. 
Criminal,    the    congenital.     120. 
Criminology,    105. 

—  system  of,   103. 
Cruelty  to  animals,   264. 
Cullen,    34,    41. 

Culture,  intellectual,  of  ancient  times, 

20. 
Cunnilinctus,    337. 
Curatelle,  26. 

—  on    account    of    Insanity,    26. 

—  see    Guardianship. 

Damerow,   44. 

Dance  madness,  29. 

Deaf,  hallucinations  of  hearing  in  the, 

T42. 
Debitum    conjugale,    334. 
Decency,    infractions    against,    340. 
Decussation,  law  of  cerebral,  known  to 

Galen,  25. 
Defectives,  403. 

Defensive    ferments,    51,    90,    126. 
■ diagnostic  value  of,  93. 


Defensive  ferments,  many  kinds,  94. 

mode  of  action,   94,   95. 

see  Abderhalden. 

Degeneracy,  psychic  signs  of,  124. 

—  signs   of,    120. 

—  transmission  of  the  germs  of,  45. 
Degenerative   signs,   58,   59,   117,    123, 

124. 
D«euze,   311,   322. 
Delinquents,    juvenile,    61. 
D61ire   retrograde,   169. 
Delirium,   acute  alcoholic,  memory  in, 

171. 

—  acutum,    214. 

—  and  epileptic  spells,  292. 

—  and  meningitic  manifestations,  293. 

—  chronic,  differentiation  from  paresis, 

171. 

—  hallucinatory,  257. 

—  of  fever  and  infections,  the,     215. 

—  tremens,    213,    288,    289,    290.    291. 

292. 

delusions  of  grandeur  in,  156. 

Delusion,    the,    of    hearing    one's    own 

thoughts  expressed,  223. 
Delusions,   151. 

—  analysis    of,    151. 

—  arising    from    hallucinations,    217, 

218,  219. 

—  as  a   basis  of  mental  disorder,   12. 

—  aspersive,    294. 

—  beginning  in   early    childhood,    226. 

—  chronic    progressive    edifice    of,    in 

paranoia,    222,    223. 
— ■  contents  of,  and  disorientation,  134. 

—  depressive,  157,  238. 

— 'erotic    character    of,    226. 

—  expansive,   224. 

—  fundamental    principles    of    the,    in 

paranoia,     220. 

—  hypochondriacal,    239,   285. 

—  in  mania,     233. 

—  in  melancholia,    238. 

—  kinds  of,  151. 

—  nihilistic,    157. 

—  not  necessary  for  the  annulment  of 

responsibility,    12. 

—  of  depreciation,   222. 

—  of   grandeur,    225,    294. 

and    delusions    of    disparage- 
ment, associated,  154. 
facial  expression  in  111. 

—  of  jealousy,   294. 

—  of  persecution,  222,  225. 

—  of   reference,    222. 

—  of   sinfulness,    238. 

—  of  suspicion,    238. 

—  of    transformation,    239. 

—  paranoiac,    293. 

—  paranoid,    239. 

—  persecutory,    152,    294. 

—  religious,  226,  238. 

—  systematization    of,    221. 
Demeanor,    theatrical,    of    paranoiacs. 

224. 

Dementia,  8. 

Dementia  paralytica,  211,  219,  228, 
238,  242,  296,  297. 

■ —ideas    of    persecution    in,    153. 

Dementia  praecox,  89,  133,  198f,  398, 
402. 

■ and  simulation,  113. 

— '  —  a    psychosis   of   early    life,    197. 

■ breakdown  products  in  the  cir- 
culation,   51. 

■ defects  of  memory  in,  165. 

—  —delusions    of    sinfulness    in,    159. 
■ forms  of,   196. 


INDEX 


417 


Dementia  praeeox,  importance  of  early 
recognition,   187. 

Dementia  praeeox  katatonica,  207f. 

augmented     suggestibility     in, 

207. 

course    of,    209. 

diagnosis  of,    210. 

• — ■ — - — differential  diagnosis,  210,  211. 

■ forensic   aspects    of,    211. 

• remissions    in,    209. 

■ sense   disturbances    in.    207. 

mistaken  for  hysteria,   198. 

■ mistaken    for    melancholia,    196. 

paranoides,   136,   137,   203f,   216, 

227. 

■ — ■ confabulations    in,    204. 

delusions    in,    204. 

differentiation  from  hallucina- 
tory   confusion,    206. 

from  paranoia,     206. 

■  —  from    dementia    paralytica, 

206. 

■  —  mania  of  obsession  and  pos- 
session in,  205. 

• — • mannerisms,     negativism     and 

automatism  in,   204. 

new    word    constructions    in, 

205. 

sense  deceptions  in,   204. 

— the  memory  in,   205. 

prognosis  of,  196. 

See    Juvenile    dements, 

simplex,    197,    258. 

1 — consciousness    in,    199. 

course   of,    201. 

delusions    and     hallucinations 

in,   199. 

differentiation    from    hysteria, 

epilepsy,    neurasthenia,    manic   de- 
pressive insanity,  202. 

end  results  of, 

mistaken  for  melancholia,  hys- 
teria or  neurasthenia,  202. 

perception    and    apperception, 

199. 

posture  in,  201. 

prognosis  of,  201. 

— ■ the  emotional  sphere  in,  199. 

■  —  the   memory,    199,   200. 

statistics,  96. 

—  presenile,  361. 

—  senilis,  228,  277f,  297. 

—  the  face  in,  111. 
Demonic    possession,    7. 
Depression,    258. 

—  agitated,   with   flight  of  ideas,   246. 

—  melancholic  and  normal,  compared, 

235. 

—  sorrowful,  235,  236. 
Descartes,    33. 
D6sequilibr6s,    124. 
Despair,    outbreak   of,   237. 
Determination,   80,  82. 
Development,  disharmonious,  264. 

—  premature,    264. 
Diagnosis,  90. 

—  early,    99. 

Diagnostics,  special,  of  mental  disor- 
der,  182f. 

Disequilibrum,    265. 

Disorientation,  133,  134,  136,  270, 
278. 

Disparagement,   ideas   of,    151. 

Disposition,  congenital,  68. 

—  inherited,   68. 

—  latent,  69. 

—  psychopathic,    64. 

—  to  disease,  47. 


Dissimulation,   100,   113,   139. 

—  objective  signs  of,   114. 
Dissipation,   77. 
Dornblueth,  116. 

Doubtful    states,    testimony    in,    4. 

Dreamy  states,   269. 

Dress,    eccentricities   of,    226. 

Drunkenness,   277. 

Dubois,    160. 

Dyschromatopsia,    254. 

Ear,  the,  123. 
Ecstasy,    pathetic,    208. 
■ —  religious,    257. 
Echo  des  pensSes,   147. 
Education,  misdirected,  61. 

—  neglect    of,    individual    peculiarities 

in,    59. 
Effeminatio,    351. 
Efficiency  and  disordered  function,  64, 

65. 

—  average,     67. 
Egotism,    252,    265. 

—  in  hypochondriasis,  285. 

—  in    morphinists,    301. 
Emotional    change,    sudden,    108. 
Encephalopathia  saturnina,  191. 
Energy,   return   of,    237. 

England,    as  a   leader   in   the   care   of 

the   insane,   41. 
Environment,    65,    76. 
Epilepsia  nocturna,  269. 
Epileptic,    alcoholic    delirium    in    an, 

290. 

—  attacks  in  alcoholism,   298. 

—  facial   expression   of  the,   111. 

—  states,  paranoid  delusions  in,    163. 

—  temperament,  271. 

—  twilight    states,    135. 
Epileptics,    14,    89. 

—  as  exhibitionists,   341. 

—  as  tramps,  thieves  and  prostitutes, 

274. 

—  false   accusations   of,    172. 

—  hysterical    traits    in,    271. 

—  ideas  of  sinfulness  in,  158. 
Epilepsy,    8,    190,    202,   211,    216,   219, 

259,    266f. 

—  amnesia  in,   166,   167. 

—  and   crime,   12. 

—  as  described  by  Hippocrates,  23. 

—  association  test  in,   178. 

—  augmented    sexual   impulse   in,    333. 

—  differential   diagnosis  of,   272. 

—  forensic    aspects    of,    273,    274. 

—  frequency   of   attacks   in,    271. 

—  Jacksonian,    185. 

—  prognosis    of,    271. 
Erotomania,   333. 

Esquirol,    41,   42,   140,   142,   220. 
Eugenics,    45.  * 

Eulenburg,    333. 
Euphoria,    193,    229. 
Exaltation,    maniacal,   208. 
Examination  of  the  insane,  98. 

—  physical,    109. 
Excitement,   manic,   257. 
Exhaustion    delirium,    214. 
Exhibitionism   in   women,   342. 
Exhibitionists,    341. 
Exophthalmic    goitre,    92. 
Expert,   forensic,   98,  99. 

—  opinion,    6,    15. 

—  —  a  statement  of  facts,  360. 

■ based  upon  observation,   360. 

formation    of,    359f. 

'practical  examples  of,  359f. 

variance  of,   35. 


418 


INDEX 


Expert  psychiatric,  the,  90. 

—  the,  as  a  public  official,  48. 

—  the   medical,   under   the   Greeks,   35. 

—  the  physician  as,  in  Roman  law,  35. 
Expression,   facial,   109,    110. 

Galen,    23,    24,    35. 
Galenic  medicine,   24. 

—  psychiatry,    24. 
Gall,   43,   121. 

Gastro-intestinal    tract,    disorders    of, 

256. 
Gesture    in    insanity,    111,    112. 
Gheel,  44. 

Gilles  de  la   Tourette,   314,   320. 
Glandular   organs,   91. 
Globus,    254. 
Goiter,   49. 

—  and   psychic   functions,   117. 

—  exophthalmic,    92. 
Griesinger,    44. 

Guardian,   appointment  of,  5. 
Guardianship,    47,    100,   282. 
— i  and    lucid    intervals,    26. 

—  in   Roman  law,   26. 

—  proceedings,    361. 

—  see    Curatelle. 
Gudden,    45. 

Guilt  in   criminal  law,   80. 
Guislain,    43. 
Gynandria,    351. 

Haeser,    22,    24. 

Hahnemann's   vitalistic  views,   40. 

Hair,    the,    122. 

—  in  various  forms  of  insanity,  116. 
Haller,    34,    38,    39. 
Hallucination,     in    various    languages, 

146. 
Hallucinations,     140,     142,     223,     239, 
293 

—  auditory,    144,    145,    146. 
-and   visual.   290. 

—  —  upon  one  ear  only,  145. 

—  isolated    auditory,    222. 

—  of    body    sensation,    150. 

—  of  general  sensation,   148,   150. 

—  of   memory,    109. 

—  of   taste   and   smell,    148. 

—  visual,    147,    148. 
Hallucinatory  confusion,  136,  137,  217, 

281 

—  insanity,   214,   215,   217,   218,   219. 
differential    diagnosis,    219. 

—  —  insight  into  condition  in,   218. 
prognosis    of,    218. 

remissions  in,    218. 

Hallucinosis,  acute  alcoholic,  293,  294. 

—  of    alcoholics,    398. 
— rof  cocainists,   304. 

—  of  drinkers,    288. 
Hammond,    William    A.,    330. 
Handwriting,    119,   130,   131. 
Hasheesh,    304. 

Head,   examination   of   the,   122. 
Health  and  disease,   no  sharp  dividing 

line   between,   53. 
not    antithetical.    55. 

—  equal    balance    of   activities   of   life 

in,  55. 
Hearing,    hallucinations   of,    291. 
Hebephrenia,   197,  198. 

—  depression  and  paranoid  notions  in, 

198. 

—  mannerisms  in,   198. 

—  religious    delusions    in,    198. 

—  states  of  excitement  in,  198. 
Heilbronner,    100. 


Heinroth,  38. 
Heliotherapy,    32. 

Hellenic  influence   upon    Roman   medi- 
cine, 23. 
Heredity,    69. 

—  effects  of  alcohol  upon,  71. 

—  forms  of,   104. 

—  Mendelian  law  of,  45,   104. 

—  taint,   102,   105,  106,  263. 

—  transmission   of   acquired   peculiari- 

ties, 70. 
Hermaphrodite,   psychic,   353. 
Hermaphrodosia,    350,   351. 
Hippocrates,  22,  23,  24,  29,  30,  31. 

—  views  of,  on  health  and  disease,  22. 
Hoche,    331. 

Homosexual   desire    as   a   degenerative 

symptom,    349. 
■ — ■  paranoia,    347. 
Homosexuality,  350. 

—  and    sexual    symbolism,    349. 
Horn,   43. 

Huebner,   211. 

Human     beings,     divided     into     three 

classes,  54. 
Humanists,     influence     of     the,     upon 

medicine,  30. 
Humiliation  as  a  Sadistic  act,  344. 
Huntington's  chorea,  275. 
Hydrocephalus,  the  skull  in,  122. 
Hyperesthesia.     118. 
Hyperlagnia,    333,    334. 
Hyperhedonias,    331. 
Hyperosia,    333,    334. 
Hyperthyroidism,   92. 
Hypochondriasis,    159,    284. 
Hypomania,    232. 
Hypnogenic    zones,    321. 
Hypnosis,  82,  309f. 

—  a  pathological   state,   319. 

—  due  to  suggestion,   319. 
Hypnotic    experimentation,    325. 

■ —  influence,    legal    relations    of,    309, 

310. 
Hypnotism,   the  doctrines  of,   312. 
Hypnotization    without    consent,    320. 
Hypnotized    individuals    as    hysterics, 

326. 
liability    and    responsibility    of, 

324. 
Hypoglossal  innervation,  129. 
Hypophysis,    tumors   of,    89. 
Hysteria,  50,  202,  211,  250f,   287. 

—  calumnies    in,    150. 

—  delusions  in  the  twilight  states  of, 

154. 
— Repressive    ideas    of,    158. 

—  differential    diagnosis    of,    258. 
Hysteria,     forensic    aspects    of,    259. 

—  prognosis   of,    258. 

—  the  four  phases  of,  255. 
Hysterical  attacks,  amnesia  after,  168. 

—  character,    the,    286. 
• —  paralyses,    132. 

—  temperament,    271. 

—  traits  in   morphinists,   302. 
Hysterics,  ideas  of  persecution  in,  154. 
— i  slanderous    accusations   of,    172. 
Hystero-epilepsy,     272. 
Hystero-hvpochondriasis,    150,    159. 

258,  284,  280. 

Ideler,    38. 
Idiocy,    8. 

—  augmented   sexual   impulse   in,    333. 
Idiots  and  cretins,  speech  in,  130. 

—  and    imbeciles,    association    test   in, 

178. 


INDEX 


419 


Illusions,  140,  141,  142,  143,  144,  239. 

—  and  hallucinations  in  mania,  233. 
Imagination  and  reality,  139. 
Imitative    impulse,    209. 
Immigrants,    71. 

Immoral  acts,  committed  by  senile  de- 
ments,   364. 

—  behavior,    277. 
Immunity,  73. 

—  racial,    74. 
Imperative    acts,    14. 
Impulse,    morbid,   3. 
Impulses,  morbid,  13. 

—  obsessional,    14. 

—  pathological,   83. 
Impulsive  acts,   208. 
— •  insanity,  13. 
Imputability,    80. 
Imputation,  notions  of,  152. 
Inactivity   of   the   will,    236. 
Incendiarism,    259. 

Index,  numerical,  for  estimating  intel- 
ligence   or    feeblemindedness,    177. 
Individuality,  65. 

—  and  hypnotic  influence,  317. 

—  suppression  of,   76. 
Individuals,  peculiar,  60. 
Induced    insanity,    379. 
Inductive    method,    43. 
Inebriety,  82. 

—  pathological,      forensic     importance 

of,  289. 

—  pathological  states  of,  288. 
Infanticide,  364. 
Infantilism,    89. 
Infectious    processes,    89. 
Inferiority,  psychopathic,   49. 
Inhibition,   236,   237. 

—  of  thought,   239. 

—  manic,  of  thought  processes,    247. 
Insane,   institutions  for  the  quiet,   29. 

—  release  of  the,  from  prisons,    41. 

—  the,  as  compared  to  an  infant  or  an 

animal,   9. 

—  the,  believed  to  be  witches,  21. 

—  the,   not  supposed  to  be  sick,   9. 

—  treatment  of  the,   at  the  time  of 
Luther,  37. 

Insanity,   as   a   disgrace,   84. 

—  classification,   85. 

—  definition  of,  78. 

— -  extrinsic  causes  of,  77. 

—  hysterical,    256. 

— 'inheritance  of,  105. 

—  in    primitive    peoples,    74. 

—  periodic,    84. 

—  recognition    by    the    layman,    84. 

—  structural  changes  in,  85. 

—  transitory,    in    ancient    times,    22. 

i —  treatment  of,  by   exorcism  and  im- 
prisonment,  29. 
Insight,  lack  of,  81. 
Instability,   251. 
Institutions,  special,  for  constitutional 

inferiors,   266. 
Instruction  and  training,   59. 

—  in  Paris  in  1817,   41. 

Intellect,    the,    in    chronic   alcoholism, 

297. 
— 'the,  in  morphinism,  301. 
Intellectual  weakness,  175. 
Intelligence.  161,  240. 

—  test,   173,   174,    177,   179. 
Internal  secretion,  91,  92,  126. 

—  mutational   relations   of.    92,   95. 
Interpretation    of    facts,    19. 
Intoxication,    289. 

—  psychoses,  the,   288. 


Inventiveness,   tendency   to,   224. 
Investigation,  inductive  method  of,  20, 
Isolation  of  the  insane,  26. 

Jacobi,   K.   W.   M.,    44. 
Janet,    314. 
Jealousy,  223. 

—  delusions  of,  300. 
Jessen,  44. 

Judgment,   161,   174,   278. 

— disability   of,    175. 

Jurists  as  laymen,  7. 

Justiniam,    Emperor,   35. 

Juvenile  dements,  credulity  of,    200. 

difficulty    of   training,    200. 

speech    in,    200. 

stunted    emotional    life    of,    200. 

—  - —  voracity  of,   200. 
writings  of,  200. 

Kahlbaum,    212,    213. 

Katatonia,  89,  211,  212,  213,  217,  247. 

—  prognosis  of,   213. 
Katatonics,  tuberculosis  in,  125. 
Kiernan,    330. 
Kleptomania,    erotic,   339. 
Koch,     49,     263. 

Kornfeld,   31,    35. 

Korsakoff's  psychosis,  288,   294f,  300. 

'disorder  of  memory  in,  165. 

—  —  senile,    171,    279. 

syndrome,     171. 

Kraepelin,   46,   196,   212,   243. 
Krafft-Ebing,    50,    330,    331,    333,    338. 

348,   349,   351,   352,   354. 

Lachrymation,   122. 

Lagnanomania,    342. 

Langermann,  43. 

Lasciviencies,    339,    340. 

Laws,  modification  of  antiquated,    6. 

Lead  intoxication,  305. 

—  poisoning,    191. 
Lesbic  love,   351. 
Letterwriting,    245. 
Liebault,    312,    318. 
Liebig,   60. 

Life  in  the  city  and  country,  74,  75. 
Litigants,  difference  between  mentally 

healthy  and  insane,  226. 
r —  paranoiac,     resemblance    in     action 

of  all,   225. 
Localization,  principle  of,  43. 
Logorrhcea,  230. 
Lombroso,  120,  331,  338,  349. 
Loquacity,   232. 
Lubarsch,  68. 
Lucid  intervals,  248. 
Lust  murder,  344. 
Luther's  proposal  to  drown  an  idiotic 

child,  37. 
Lydston,  330. 
Lykanthropy,   29. 

Machlachomania,   345. 
Macrocosm,    31. 
Magnan,  203,  263. 
Makropsia,  148. 
Mania,   210,   216,  229. 

—  acute,    grandiose    notions   of,    156. 

—  association  test  in,  178. 

—  augmented   sexual  impulse  in,   333. 

—  course,    231. 

—  delirious,  233. 

—  differential  diagnosis,  233. 

—  forensic    aspects,    234. 

— .melancholia    and    manic    depressive 
insanity,    229f. 


420 


INDES 


Mania,  paretic,  193. 

—  periodic,    244, 

—  temperature  in,   118. 

Manic    depressive    insanity,    202,    228. 

243,    281. 

as   a   permanent   state,   247. 

differential  diagnosis,    247. 

duration    of    attack,    247. 

■  forensic   aspects   of,   248. 

Manic    depressive    psychosis,    11. 

■ augmented  sexual  impulse  in, 

333. 

— ■ delusions  ot  sinfulness  in,  158. 

Manic    stupor,   246. 

Manifestations     of     life,     always     the 

same,    19. 
Mannerisms,   208,  209. 
Marriage  and   promise  to  marry,  282. 
Masochism,    345. 

—  and    fetishism,    346. 

—  in  women,  347. 
Masturbation,  208. 
Mediaeval    psychiatry,    29. 

Medical    system,     new,    of    the    18th 

Century,   40. 
Medicine  among  the  Romans,   23. 

—  Egyptian,      Judaic      and      Oriental, 

22. 
Melancholia,    191,    219,   234,   251,    258, 
285,    286,    287,    403. 

—  and  mania,   as  interpreted  by  Hip- 

pocrates, 22. 

—  differential    diagnosis,    242. 

—  differentiation   of,   240. 

—  duration  of,  240. 

—  expansive   notions  in,   156,   158. 

—  forensic    aspects,    241. 

—  hypochondriacal  complaints  in,  160. 

—  hypochondrique,    284. 

—  intellectual     and     emotional     disor- 

ders in,  235. 

—  Juvenile,    196. 

—  kinds   of,   240. 

—  persecutory   delusions  in,    154. 

—  prognosis  of,    241. 

—  reasoning,    246. 

—  refusal  to  eat  in,  240. 

—  self-accusations  in,   101. 

—  speech  and  writing,  in,  120. 

—  temperature   in,    118. 

—  tendency  to  suicide  in,  240. 
Melancholiac,  thought  contents  of  the, 

236. 
Memory,   161,   240,   245,   279,   297. 

—  and  intelligence,  no  parallelism  be- 

tween,  174. 

—  anterograde,    291. 

—  disorder,    278. 

and  confabulation,  171. 

—  disorder  of,  for  recent  events,  171. 
— ■  for  recent  events,   295. 
manner    of    testing,    164. 

—  for    the    distant    past,    manner    of 

testing,  161. 

—  hallucinations    of,    171. 

—  illusions  of,   141,   171. 

— 'in  acute  alcoholic  delirium,   171. 

—  in  morphinism,  301. 

—  retrograde,    291. 

—  suggested   loss  of,  325. 

—  suggestion    and    the,    316. 

—  test,   163,   173. 

—  the,   in   neurasthenia,   262. 
Mendel,   Johann   Gregor,   69. 
Mendelian     law,     applied     to     human 

heredity,    70. 

of   heredity,    45. 

Menstruation,   119,  127. 


Mental  activity,  haste  and  vehemence, 
in,   231. 

—  behavior,  testing  the,    132. 

—  deficiency   in   neurasthenia,   260. 

—  disease   and   modern   life,  21. 

in  ancient  times,  21. 

is  bodily  disease,   28. 

misleading  term,   28. 

—  diseases,  earliest  manifestations  of, 

86. 

exogenous  causes  of,  73. 

primary,    86. 

recovery   in,   86. 

—  disorder,    secondary,    symptoms    in, 

85. 
— ■  —  the    notion    of,    53. 

—  disorders,  the  diagnosis  of,  89. 

the  early  recognition  of,  87. 

f — health,  not  certifiable,  15. 
Mesmer,   310. 

Metalbolism,   88. 

Metzger,  36. 

Meyer,   Adolf,   264. 

Meynert,  230. 

Microcephaly,   117. 

Microcosm,   31. 

Micturition,    125. 

Middle  ages,  influence  upon  medicine, 

26. 
prejudice  and  superstition  of  the. 

29,   30. 
— -  —  psychiatry    during    the,    20. 
Migraine,  periodic,  269. 
Mikropsia,    148. 
Mind,  the  science  of  the,  as  a  branch 

of  the  natural  sciences,  20. 
Misophobia,   262. 
Model  pupils,  60. 
Moll,    330,    339. 
Monomania,    220. 
Moral  degeneration,  298. 
Morality,  330. 

Moral  sense  in  senile  dementia,  363. 
Morbid  ideas,  concealment  of,  10. 

—  impulses,  80. 
Morel,   104. 

Morphinism,    301,    302. 
Motility,  disorders  of,   254. 
Mott,    183. 

Mueller,  Johannes,  35,  40. 

Multiple    neuritis    and    delirium,    295. 

Mutism,    129,    130. 

Mysticism   and   speculation,  38. 

Mythology  of  the  Greeks,  24. 

Myxoedema,   89,    92. 

Nancy   School,   teachings  of  the,   313, 

318. 
Nasopharyngeal   vegetations,     49. 
Nasse,    43. 
Negativism,    251. 

—  in  dementia  praecox  katatonica,  207. 
Neomnemnesis,   161. 
Neurasthenia,   189,   260f. 

—  and  dementia   praecox,   197. 
— 'causes    of,    260,    261. 

—  forensic  aspects  of,  262. 
Neuropathic    degeneration,     337. 
Neuropsychoses,    250f. 

—  due  to  accident,   258. 

New   impressions,   power  of  retaining, 

363. 
Noguchi,    45. 

—  and  Moore,  183. 

Normality,  not  a  fast  and  inalterable 

state,   54. 
"Normal   type,"  64. 
a  fiction,  54. 


INDEX 


421 


Non-restraint   system,   43. 
Notoriety,   love  for,   252. 

Observation   of  the   patient,    108,    109. 
Obsessions    in    neurasthenia,    262. 

—  uncontrollable,  4. 
Ocular    muscles,    129. 

Odor   of    body    in   insanity,    115. 

Oken,   40. 

Ophthalmoscopic  examination,   132. 

Opium,  304. 

Orientation,    133,    136,    138,    240. 

—  for  time.  164. 

—  test,   136. 
Ovarial   secretion,   92. 
Overburdening  in  school,  75. 
Overexertion,   76. 

Paedicatio,    350. 

Pain  and  pleasure,  expressions  of,  59. 

Paleomnemnesis,    161. 

Paracelsus,    37,    38,    310. 

—  a   transition   from   the  middle  ages 

to  modern  times,  31. 

—  views  of,   31,   32. 
Panesthesia  sexualis,  334. 
Parahedonias,   331. 

Paranoia,   219f,   242,   283,   287,   398. 

—  alcoholic,  288,  299. 

—  depressive  ideas  in,  158. 

—  differential    diagnosis,    227. 

—  forensic    aspects    of,    227. 

—  hypochondriacal   delusions    in,    159, 

160. 

—  litigious  form,   225. 

— '  persecutory  delusions  in,    153. 

—  primary  character  of,  220. 

— 'transmutation    of    memory    images 
in,  169. 

—  with    the    notion    of    promoted    in- 

terests, 221. 

— 'With    the    notion    of   restrained    in- 
terests, 221. 

Paranoiacs,   querulant,   155. 

Paranoid  dementia,  280. 

Parerosia,  334. 

—  acquired  homosexual,   352. 

—  homosexual  in  the  female,  351. 
in  the  male,  350. 

—  psychopathological     significance    of 

homosexual,   353. 
Paresis,  8,  89,  183,  248,  281,  284,  376. 

—  alcoholic  intoxication  in,  190. 

—  alteration  of  character  in,   188. 

—  apathy  in,  191. 

—  classification,  188. 

—  conjugal,   183. 

— 'defective  response  of  knee  jerks  in, 
184. 

—  defects  of  memory  in,  162,  163. 

—  delusions   in,    189,    191. 

—  delusions  of  grandeur  in,  193,  194. 

—  diagnosis   of,   156. 

—  differential  diagnosis,  189,  190,  191. 

—  differentiation    from    acute    mania, 

194. 

—  differentiation     from     chronic     de- 

lirium,  171. 

—  differentiation  from   circular  insan- 

ity,    194 

—  differentiation    from    katatonic    ma- 

niacal   states,    194. 
— i  differentiation     from     melancholia, 
192. 

—  differentiation   from   paranoia,    192. 

—  disordered  reflexes,  185. 

—  disorders    of    intelligence,    186. 

—  disorders   of  memory  in,   186,   189. 


Paresis,  disorders  of  moral  sensibility 
in,  186. 

—  disorders  of  motility,   185. 

—  disorders  of  sensibility,  185. 

—  disorders    of   the   nerves    of   special 

sense,  185, 

—  disturbances  in  reading,   185. 

—  disturbances    of    handwriting,    185. 

—  duration  of  the  agitated  form,  194. 

—  early  diagnosis  of,  187. 
— ■  early    onset   of,    188. 

—  euphoria  in,   191. 

—  expansive   or   classic  form   of,    193. 

—  facial    expression    in,    111. 

—  fantastic    confabulations    in,    193. 

—  forensic  aspects,   195. 

—  galloping,    194. 

—  grandiose  ideas  of,  155. 

—  hallucinations  in,  191. 

—  hypochondriacal  complaints  in,  160. 

—  importance     of     early     recognition, 

187. 

—  in    Scotland,     Ireland    and    Wales, 

73. 

—  juvenile,  188. 

, —  low  association  breadth  in,   177. 

—  melancholic   delusions   in,    158. 

—  memory    for    recent   events   in,    165. 
— ■  mistaken  for  neurasthenia,  187. 

—  paralytic  attacks  or  spells  in,  185, 

186,    189. 
— ■  pupillary   disorders    in,    184. 

—  remissions  in,  11,  189,  195. 

—  speech    disorders    in,    184. 

—  spirochiEta    in,    45. 

—  states  of  fear  in,  191. 

—  temperature  in,  118. 

—  the  agitated  form  of,   194. 

—  the    depressive    form    of,    191. 

—  the  handwriting  in,  188. 

—  the  speech  in,  188. 

—  Wassermann    reaction    in,    184. 
Paretics,    civil   actions   against,    195. 

—  criminal  charges  against,     195. 

—  guardianship    of,    195. 

— ■  incompetency  or  irresponsibility  of, 
195. 

—  marriages  of,  195. 

Paris  school,   teachings  of  the,    313. 

318. 
Parturition,    disordered    consciousness 

during,     373. 
Pathological      qualities,      transmission 

of,    69. 
Pathology,    experimental    influence   of, 

42. 
Peculiarities,   individual,    55. 

—  tranmission   of,   69. 
Peepers,  340,  341. 
Perfect,   William,   41. 
Persecution,    notions    of,    223. 
Personality,    alteration    of,    106,    107. 

—  the    hysterical,    251. 

—  the,  in  paranoia,  223. 

—  transformation  of,  78. 
Petetin,    311. 
Philosophy,  27. 

—  scholastic,    20. 

—  theology  and  scholasticism,  28. 
Photographs  of  the  insane,  116. 
Phrenology,  121. 

Phthisis,  disposition  to,  68. 
Physical  examination,  120. 
Physician's,  liability  for  hypnotization, 

320. 
Physiognomv,  the,  in  dementia  prsecox 

katatonia,   207. 

—  the,   of   the   insane,   116. 


422 


INDEX 


Physiological     and     pathological,     not 

sharply  separated,  54. 
Pinel,   41.   42. 
Pitres,  324. 

Poisoning,   delusions   of,    300. 
Polyneuritic    psychosis,    294. 
Poromanla,   2(59. 
Posture     in     dementia     pra;cox     kata- 

tonia,    20S. 

—  in   insanity,   111,   112. 
Potentiality    of    guilt,    80. 
Predisposition    to    disease,    65,    66,    67, 

70. 
Prejudices,   exchange   of  old   for   new, 

8. 
Presenile  delusional   insanity,   228. 

—  dementia,     defects    of    memory    in, 

165. 
legal    protection    in,    363. 

—  insanity,   282,   283. 

—  paranoid    state,    281. 
Previous  history,    106. 
Priapism,    334. 
Prichard,  263. 

Prognathism,    117,    122,    124. 
Prognosis,    medico-legal,    404. 
Prostitution    in  drug   addicts,    301. 
Protection  and  defense,  the  organism's 

means  of,  92. 
Psychasthenia,    261. 
Psychiatric  testimony,   16. 
Psychiatry   among  the   Romans,   23. 

—  as   an    intellectual    science,    28. 

—  decline  of,  during  the  middle  ages, 

34. 

—  development  of,   20. 

—  foundation  shaken  by  scholasticism, 

34. 

—  growth  of  the  French  school  of,  42. 
— hippocratic,    23. 

—  influence  upon  forensic  medicine,  20. 
— •  in   France,    41. 

Psychic    activity,    83. 

—  functions   and   physical  alterations, 

44. 

—  influence   of,    upon    the   activity    of 

the  body,  40. 
— ■  inferiors,  260. 
j—  investigation,   physiological  method, 

44. 
Psychogeny,    250. 
Psychology,   part  of  the  physiology  of 

the    brain,    58. 
Psychomotor  confusion,   215. 

—  excitement  in   mania,  233. 
Psychoneurosis,    50. 
Psychopathic   constitution,   36. 
— 'disposition,   97. 

—  personality,    symptom    complex    of, 

396. 

—  taint,  66,  70,  77,  78,  79. 
Psychophysical    parallelism,    64,    97. 
Psychoses,  always  the  same,  19. 

—  and  neuroses,  defensive  ferments  in, 

51. 

—  as  brain  diseases.  23. 

—  as  something  reprehensible,   9. 
■ —  in  chorea,  275. 

—  material  basis  of,  58. 

—  the,  as  actual  physical  disorders,  94. 

—  weight  in   chronic,   118. 

Public  menace,  individuals  who  are  a, 

403. 
Pulse.    128,    215. 

—  the,  in   insanity,  118. 
Pupils,    the,    128. 
Puysegur,  310,  322. 
Pygmalionism,  342. 


Querulants,    155. 

—  and    litigants,    persecutory    notions 

in,   153. 
Questionable   states,   10. 

Raecke,   331. 

Raptus    melancholicus,    238. 
Ratisbon,  diet  of,   35. 
Recognition    and    knowledge,    19. 

—  mistakes  of,   143. 
Recollection,  142. 

Regeneracy,  transmission  of  the  germs 

of,  45. 
Reil,  34,  39,  42. 
Report,   forensic,   98. 
Reproduction,  powers  of,  230. 
Resistance,   power  of,  66. 
Responsibility,   11, 
- — and  delusions,   12. 

—  and      free     determination,      Roman 

views,  25. 

—  and   irresponsibility,   62,   81,   260. 

—  diminished,   47,    48. 

—  in  alcoholic  psychoses,   300. 

—  in  alcoholism,  12,  13. 

—  legal,  15. 

—  mental  disorders  and,  80. 

—  partial,  14. 

—  physiologic-psychologic  basis,    80. 

—  restricted,    82. 
Restraint,   measures  of,  44. 
Rhachitis,  117. 

Right  and  wrong  test,  11. 

Rights,    disregard    of    other    person's, 

265. 
Richer,   Paul,   312,  313,   321. 
Romans,  legal  relations  of  the  insane 

among  the,  23. 

—  psychiatry  among  the,   23. 

,Sade,  Marquis  de,  343. 
Sadism,  342,  343. 

—  in  women,  345. 

Sadists  and  masochists,  common  traits 
of,  347. 

Salivary   secretion,    119,    125. 

Sapphic  love.   351. 

Satyriasis,  333. 

Savage,  73. 

Schelling's  philosophy  of  nature,  38. 

Scholastic    philosophy,    26. 

Scholasticism  and  the  classic  philoso- 
phy of  the  ancients,   27. 

—  in    the   middle   ages,    27. 

—  restraining   influence   upon   psychia- 

try,  28. 

—  the  prominent  trait  of,  27. 
Scholz,  70. 

School's   demands,    60. 
Schrenck-Notzing,    49,    330. 
Schroeder  van  der  Kolk,  43. 
Secretions,    internal.    88. 
Self-accusations,  4,  236. 

—  of  the  insane,  48. 
Self-appreciation,    231. 
Self-control,  loss  of,  12. 
Senile   confusion,   279. 

—  dementia,    190,    191,    242,    284,    363. 
confabulations    in,    171. 

defects  of  memory   in,    162,   163, 

164. 

depressive  state  in,    159. 

differential    diagnosis,    280,    281. 

forensic   aspects,   282. 

ideas  of  gmndeur  in,  155. 

sexual   Impulse  in,  332. 

—  dements,    a    prey   to    swindlers    and 

adventurers,    364. 


INDEX 


423 


Senility,  8. 

—  differential    diagnosis,    155. 

—  symptoms  of,   363. 
Sensation,   disorders   of,    253. 

Sense  deceptions,    107,    108,   109,   150, 
215. 

and  objective  signs,  113. 

in  presenile  insanity,  283. 

of  a  sexual  nature,  149. 

tactile     291. 

Serodiagnosis,    12Q,   127,   184. 

—  as  an  ally  to  psychiatry,  50. 

—  See    Abderhalden. 
Serology,   89. 

Serum    test,    as    applied    to    the    psy- 
choses, 96,  98. 
Sexual    aberrations,    334. 
forensic  import  of,  334. 

—  accusations,  260. 

—  contraventions,    330. 

—  crimes,    14,   262,    329. 

—  delicts,   forensic   evaluation  of,   330. 

—  desire  in   healthy   children,   332. 

—  in  old  age,   332. 

—  excitability,   127. 

—  hetero-,  anomalies,   335. 

—  hyperesthesia,     333. 

—  impulse,   328. 

abnormal    increase    of,    333. 

—  inversion,    347. 

—  matters,    testimony   in,    4. 

—  outrages  during  hypnosis,  321. 

—  paradoxy,   332. 

—  perversions,    49,    264,    282,    334. 
classification  of,  331,  335. 

—  perverts,  125. 

—  sense,    anachronistic    anomalies    of, 

332. 

—  sense,    anomalies    of,    328. 

—  sense    anomalies,    legal    treatment, 

354. 
Shakespeare,    10. 
Shoplifters,  259. 
Sibylline  books,  24. 
Simulants  and  dissimulants,  7. 
Simulation,   10,   37,   99,  100,   113,  167, 

252. 

—  and  dissimulation  11. 

—  and  mental  disease,  113. 

—  of  insanity,  35,  36,  389f. 
Skull,  examination  of,  121. 

—  forms  of,   121. 

—  malformations  of,  122. 

—  measurement  of  the,  121. 

—  the,   117. 
Sleep,   119. 

—  and    dreaminess,    82. 

—  and    sleeplessness,    107. 

—  the,  of  delirium  tremens,  292. 
Somnambulic   states,   256. 
Somnambulism,    32. 

Special  sense,  disorders  of,  254. 
Speech,    119,    129,    130,    245. 
disorders  of,  254,  257. 

—  manner  of,   239. 
Spendthrift,   26. 

Spirit,  the,  as  the  carrier  of  life,   40. 
Spiritists,   the  astral  body  of  the,   32. 
Spirochetes   in   the   brains    of   paraly- 
tics, 183. 

—  of  syphilis,  45. 

St.  Luke's  Hospital  in  London,  41. 

Sprenger,    32. 

Spurzheim,  43. 

Stahl,  34,  37. 

Status    psychicus,    97. 

—  somaticns,    97. 
Stigmata,  58. 


Stigmata  degenerative,  120. 

Stockard,  71. 

Stupor,    depressive,   246. 

—  temperature  in,  118. 
Succare,   337. 
Suggestibility,   250,    251. 

—  in  dementia   precox,   207,   209. 
Suggestion,  field  of,   322. 

—  hypnotic,   314. 

—  influence  of,  253. 

■ —  medico-,    legal    importance    of,    322, 
323f. 

—  negative,  316. 

—  opposition    to,    323. 

—  post-hypnotic,    314,    316,    318. 

—  retroactive,    316. 

Suicide,   as  a  punishable  offense,   7. 

—  attempts    at,    14. 

—  direct  and  indirect,  241. 
Suicides,  75. 

Supernatural,  Aristotle's  belief  in  the, 

27. 
Swindlers,    125,    259. 
Symbolism  in  Masochism,    346. 

—  sexual,    335,   337. 
Syphilis,  89. 

(Taboparesis,  45. 
Teeth,  the,  122,  123. 
Tarnowsky,  333. 

Temperament,    peculiarities   of,    298. 
Temperature,   128. 
— -of  the  body,  118. 
Testamentary  capacity,  282. 
Test  of  the  memory,  163. 
Theft  committed  by  a  paretic,  376. 
Thought  audition,  192,  293. 

—  connections,   superficial,   232. 
Thyroid   gland,   dysfunction  of,    126. 
— secretion,   92. 

Toxemia,   90,  91. 
Training,  erroneous,  62. 
Transcendentalism    in    philosophy,    27. 
Transfert,    254. 
Tremor.   129. 
Tribadism,    352. 
Tricksters,  pathological,   172. 
Truancy,  264. 

Twilight  states,  256,  257,  270,  273, 
274,   372,  373. 

—  - —  offenses  committed  in  the,  259. 
Tuberculosis  in  katatonics,  125. 

Unlawful   acts,    when   not   punishable, 

47. 
Untruthfulness,  264. 
Uremia,    190. 
Uranism,    347,    350. 
Urine,    119,    128. 
Urningism,    350,    351. 

Vanity,  265. 

Vasomotor    disorders,    118,    256. 

Verbigerations,  rhythmical,  209. 

Vesalius,  33,  34. 

Violation,   during   hypnosis,    321. 

Viraginity,    351. 

Virchow,    43,   53. 

Visions,  animal,  291. 

Visual  hallucinations,  objective  signs 
of,    114. 

Vital  force,  38. 

Vitalism,  37. 

Vitalists,  the  moderate  and  the  radi- 
cal, 38. 

Von   Ringseis,    38. 

Voracity,    127. 

Voyeurs,    340,    341. 


424 


INDEX 


Wassermann  reaction,    126. 

of  the  blood  and  spinal  fluid,  184. 

Wassermann  test,    50,    183. 

Weber,  44. 

Wegener,   96. 

Weight  of  the   body,   118. 

diagnostic    and    prognostic 

value,    127. 
Weissman,    70,    71. 
Westphal,   45,   331. 
Will,   alteration   of   activity,    14. 

—  free  determination  of  the,  14. 
Willis,   34. 

Witchcraft,   32. 

—  delusions,  33. 


Witchcraft  prosecutions,  33. 
Witch,  death  sentence  upon  a,  33. 
Witches  and  mental  disorder,  21. 
Witness   in   court,   the   hysteric   as   a, 

260. 
Word  stimuli,   176. 
Writings,   132. 

Written  compositions,  contents  of,  132. 
Wrong,   recognition  of,  83. 
Wundt,  44. 
Wyer,   32,  33. 

Zacchias,    36. 

Ziehen,  266,  331,  353. 

Zoologic  procedure,    120. 


Date  Due 

(§) 

1  x^ 

1  — 


